Agenda item

The Committee considered a report commissioned by the Leicester, Leicestershire and Rutland Health communities (that is, East Leicestershire and Rutland CCG, West Leicestershire CCG, Leicester City CCG,  University Hospitals of Leicester NHS Trust (UHL), Leicestershire Partnership Trust and NHS England) which set out the findings of the clinical audit commissioned to examine the quality of patient care for a cohort of people who died either at UHL or within 30 days of discharge where they were discharged to a different place of residence and a summary of the strategic action plan.  A copy of the report marked ‘Agenda item 9’ is filed with these minutes. 

The Chairman welcomed Carmel O’Brien, Chief Nurse and Quality Officer at East Leicestershire and Rutland CCG (ELRCCG) and Dr Kevin Harris, Medical Director at University Hospitals of Leicester (UHL) to the meeting for this item. 

Arising from discussion the following points were noted:

(i)        Concern was expressed regarding the number of issues relating to Do Not Attempt Resuscitation (DNAR) orders and it was felt that a greater emphasis needed to be placed on ascertaining if a DNAR order existed before attempting resuscitation.  UHL advised that medical staff were legally required to attempt resuscitation where the presence of a DNAR order was not known and that by October 2014 GPs would be able to share patient information with UHL electronically, including information on DNAR orders. 

(ii)       The Committee noted that issues surrounding fitness to practice following the audit had resulted in one case for UHL and three cases for primary care.  The Committee was advised that those conducting the review had the power to refer any areas of concern to Medical Directors for further investigation.

(iii)      The Committee welcomed the publication of the report and the five point action plan but noted that the majority of cases reviewed had more than one area of concern in relation to quality of care provided and were concerned that this highlighted systemic errors across the local health economy.  The Committee would need further reassurance that these issues were not still ongoing.

(iv)      It was noted that the review was a clinical audit and as such it would not normally be made public.  However, following the publication of the Francis report and consequent expectations of openness and transparency, the local health community had taken the decision to make it publicly available.  This had taken some time due to the need to provide an executive summary and the need to have made contact with relatives prior to publication.  It was noted that about a quarter of the relatives had requested a face to face meeting; feedback from these meetings was now being collated to add to the evidence base.

(v)       No similar studies had been undertaken in other parts of the country so it was not possible for statistical comparisons to be made.  However, it was noted that examinations into the quality of care usually identified around 40% of cases with issues.  In this case, the review had provided confirmation of problems in the local health economy which needed addressing.

(vi)      It was noted that, although the audit had been undertaken retrospectively, some cases had already been subject to a Serious Untoward Incident (SUI) investigation.  The cases of the majority of patients who had died in Intensive Care and many of those dying in the hospital would also have been subject to review using the established ‘Mortality and Morbidity Review’ process.  However, reviews of this type would not typically include patients who had died following discharge from hospital as there had been no central co-ordination relating to these cases until the audit had been carried out; thus it had not been possible to identify lessons to be learnt across the whole system prior to the audit.  Consideration was being given to how this issue could be addressed in the future.

(vii)    Progress in improving patient care following the audit would be monitored by the Board or governing body of each organisation.  The Better Care Together Board would hold each organisation accountable for delivery of the action plan.

(viii)   The Committee thanked the reviewers for their work in undertaking the audit and identified three themes to be addressed when officers reported back on progress with the implementation of the action plan:-

·         That the quality of end of life care needed to be improved;

·         How Clinicians addressed issues arising from deviation from standard care pathways;

·         How communication between organisations was being improved, particularly out of hours.

RESOLVED:

(a)       That the findings of the clinical audit to examine the quality of patient care and the action plan to address the areas of improvement identified be noted;

(b)       That the local health community be requested to update the Committee on implementation of the action plan developed in response to the review at a future meeting.