21/11/2008 by Patrick Keady.

While it seems obvious now, I’d never thought about equality and diversity like this before. Today I learned that equality and diversity affects all of us. Whether its because of gender, race, sexual orientation, bullying, home circumstances, nationality, disability, harassment, age, sickness absence etc.

Run by the Garnett Foundation, today’s session was all about exploring equality and diversity in relation to recruitment and selection. Using a range of interactive approaches, we practised and developed our interviewing skills. While professional actors played a number of diverse parts.

During lively interactive workshops, we explored staff retention and working cultures that foster inclusion and diversity. The training event provided a safe learning environment to highlight areas for improvement in our knowledge and understanding and also to share learning.
While I had heard a lot about the Garnett Foundation,  today’s training session met my expectations, and more.

Posted in Governance, NHS, Safety, Patrick Keady, Legislation, Patient, Strategy, Personal Development, Health and, Uncategorized | Print | No Comments »

12/11/2008 by Patrick Keady.

NHS Live has done it again! They promised lots. And then they’ve delivered so much more. Their latest outing, NHS Innovation Live, took place today at the Queen Elizabeth II Center, London.

Designed as a platform for sharing and celebrating some of the many achievements in today’s NHS, the event was hosted by Kathy Sykes, Professor of Sciences and Society at Bristol University and a Trustee of NESTA (National Endowment for Science, Technology and the Arts). Kathy has a knack for being in the right place at the right time. Not a stranger to the media, I like her balanced approach. Kathy is open to the people that she meets, while not loosing sight of the scientific rigour that she has been immersed in throughout her career.

Gill Hicks gave today’s keynote address. Gill lost both of her legs from below the knee on 7th July 2005. Gill told us about the hour or so that she was trapped in a London Underground carriage, her three cardiac arrests before she got to hospital, the make-shift stretcher used to get her there, the Paramedic who challenged discussions to pronounce Gill dead, the Consultant that told her ‘you will get better’, the nurse who got her to the hospital hairdresser just a week after the bombings, the cafeteria staff that chatted with her every morning, the physio who coached her back to her independence and the many other NHS staff that helped her through her recovery.

Interlaced with lots of humour about being Australian and some of the funnier experiences during her recovery, Gill held the mirror up to the 600 delegates at NHS Innovation Live. And what the delegates saw in the mirror, was a former NHS patient that was truly grateful for the services that the NHS provides. What they saw in the mirror was more than sufficient for many of the delegates that had travelled from near and far. And there was so much more to come.

They had many choices. Which two of the twelve breakout sessions would they attend. Did they want to learn how to release the innovator In themselves, or how social innovation can create a new model of health for men. Or maybe they wanted to know more about how Royal Bolton Hospital adopted LEAN Thinking. For the geeks, they could hear about generating and using patient stories to improve the NHS via Web 2.0 technology. Performance people could hear how an SHA is intelligently using information to the manage performance of its PCTs and Trusts. Other choices included how social and cultural background contributes to health beliefs and attitudes to mental distress, the excitement of setting up a social enterprise organization, how to nurture an idea and transform it into something really tangible and effective, exploring the role of charities and other third sector organisations in health innovation, using observation to find out what people do and how they carry out their work, improving understanding and the experience of patient and staff, and understanding mental illness from the perspective of service user.

Yet another excellent NHS Live event – well done to the NHS Live team. Why not sign up for their next event. Its free and they’re at www.nhslive.nhs.uk

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15/10/2008 by Patrick Keady.

I chaired NHS Risk Management today. Organised by the Health Service Journal, NHS Risk Management was their first conference that focussed exclusively on risk management.

Birmingham’s Centennial Centre was oozing with energy and attendees including clinical governance managers (10%), safety and health practitioners (15%), risk managers (35%) and directors (40%). And the delegates came from the full spectrum of healthcare organisations: SHA/other (5%), Foundation Trusts (10%), Independent Healthcare (20%), Trusts (30%) and PCTs (35%).

While I’ve been practicing in risk management for 20 years, I had mixed expectations of the conference …… and thankfully it was an enjoyable and informative conference. Here were some of the highlights for me.

Mark Burns, the Safety and Security Adviser at Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust reminded us of how risk management is now directly linked with Corporate Objectives. Trusts are more aware of their risk appetite - the level of risk that they are happy with. And he reflected on how reactions to incidents have improved – senior managers today ask ‘what happened?’ In the past, they would have asked ‘who did it?’

Linda Handley-Wright, the Risk Manager at Derby City PCT expanded on the theme of culture. The key is to make risk management interesting, using LEAN principles and engaging the right people. Linda added that organisations need to address different learning styles – including scenarios, what if’s and linking risk management with other initiatives via training needs analysis. In Derby, they’ve taken Standards for Better Health as the basis of something much better - they’ve produced the Healthy Derby 10-year plan aimed at improving health, commissioning and engagement.

And engagement was a key message from Dr Anne Dyas, a Consultant Microbiologist at Worcestershire Acute Hospitals NHS Trust. Dr Dyas urged that ‘we (people involved in managing risks) must get out there and teach. To be prepared to defend changes in practice with robust evidence’. She warned that changes introduced simply for public relations reasons will not be sustainable. Jobs done in haste will probably be done badly. Dr Dyas added that data is only as good as those that gather it – she warned against multiple data sources. Most extra tasks need extra hands and extra equipment. New initiatives must support the task (of infection prevention and control) and not add to it. And do Dr Dyas’s views work in practice? Definately. Dr Dyas’s team oversaw a significant reduction in MRSA and CDiff at their Trust and this helped them win the 2008 Oxoid Infection Control Team Award.

Anne Cleminson (Trust Secretary) and Steve Bradbury (Risk Manager) from Mersey Care NHS Trust described the key elements of Assurance at their Trust - getting buy-in from key stakeholders, Committees that are fit-for-purpose, an effective Assurance Framework and good communication. And the Trust’s biggest champions are the Non-Executive Directors because of their creativity and innovation.

Ian Strudley, Head of the Health and Social Care Services, Health and Safety Executive, reminded delegates that HSE is all about reducing the real risks – upto 250 people die every year at work in the UK and many more have serious injuries and ill health. HSE reduces the real risks, by balancing risks and benefits. He gave examples of how HSE is working in partnership with organisations such as the Healthcare Commission – agreeing the Concordat for joint working between regulatory and inspecting bodies. HSE works with the NHS Litigation Authority – workshops on stress management standards. And with respect to managing violence and aggression, it works with the NHS Counter Fraud and Security Management Service.

Stephen Williamson, the Corporate Health, Safety and Risk Adviser at University Hospital of South Manchester NHS Foundation Trust reminded us of what the ideal health and safety management system looks like - setting the policy, organizing, planning for action, measuring performance, auditing compliance and review. Steve reflected the views of many delegates with respect to NHS Patient Safety First – that it will succeed with Executive ownership, and clear commitment from clinicians, managers, corporate and support functions.

Gary Hay and David Firth, partners at Capsticks, gave an overview of key legal compliance and regulation. They described the risk-related legislation in place, CNST claims, the NHSLA risk management standards, employment legislation and stress at work. No real surprises there. And then they introduced a case-study about a patient scalded in a bath – and delegates faces lit up. The case study renewed the energy of the audience. The case study felt real and it gave the delegates and opportunity to contribute.

And then the controversial (and most thought-provoking) presentation – on World Class Commissioning. Controversial because it was close to home for many of the delegates. Roger Hymas from Humana, had recently completed a secondment as Director of Commissioning with Hampshire PCT. And he reminded us that on 4th July, the Financial Times proposed that the PCTs be turned into one giant health insurer. Roger highlighted eight ‘tests’ for insurers – and PCTs meet three of the tests, don’t meet another three and possibly meet the remaining two.

Roger identified his top-10 risks facing the NHS. And in reverse order they were:

10. The NHS will run out of money in the longterm, and not before the next general election (possibly June 2010). 2008 is the year when demand is running ahead of budgets and at the same time, PCTs are spending just 15% of what the private sector spends on managing Commissioning – the suggestion here is that PCT Commissioning functions need to be better funded and by implication, they need a greater range of skills in their teams.

9. Practice-based commissioning will not gain traction. While it is estimated that only a third of GPs will be willing and able to make practice-based commissioning deliver in the way that PBC advocates suggest, by increasing PBC activity, the NHS has the potential to redistribute significant amounts of money – with GPs switching patients from one Acute Trust to another.

8. Block contracts remain impenetrable to PCT scrutiny and validation, including mental health block contracts - see Risk 10 above about PCT Commissioning functions.

7. PCTs need to invest more in management systems. In other words if PCTS don’t put aside money to invest in management systems, they’re unlikely to get control of their PCT finances – links with Risk 10 !

6. The supply side will shrink - reducing competition and choice. This will be a consequence of Trust mergers and some of the private sector providers (including ISTCs) retreating from NHS provison

5. Patients need more encouragement to play their role in re-shaping the market. Consumer surveys consistently show that consumers want choice. Patient Choice has much more to do, if it is to achieve its potential.

4,3 and 2 - Is Monitor encouraging Foundation Trusts to be too aggressive in developing their financial strategies (?) through:
- the pursuit of earnings before interest, tax, depreciation and amortisation as a key measure of success.
- the building of significant capital reserves on FT balance sheets
- service line analysis which could lead to huge distortions in provision

PCTs that transfer money to their local FT and other providers are transferring the financial risk to themselves! They are also in danger of losing control of Commissioning. Armed with the management tools developed by Monitor, FTs may choose to cherry-pick the more financially profitable specialties and procedures. And FTs could choose to unilaterally decommission services, putting patients at risk.

1. WCC will not move fast enough - or fail.

What a thought-provoking presentation to end the day. And it suggests that provided PCTs implement robust risk management processes and they invest in management systems, then World Class Commissioning is likely to become a reality.

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23/09/2008 by Patrick Keady.

With Dr Hassan Khimji and Professor Chitta Choudhury at the RSPH launch.

I was invited to the launch of the Royal Society for Public Health this afternoon. This new Royal Society is dedicated to the promotion and protection of collective human health and wellbeing. It will advise on policy development, provide education and training services, encourage scientific research, disseminate information and certify products, training centres and processes.

Professor Alan Maryon-Davis in the inaugural chair and the chair elect from April 2009 is Dr Selwyn Hodge. Professor Richard Parish is the chief executive.

Held at the Royal College of Obstetricians and Gynaecologists, many key leaders participated, including:

-    Dame Suzi Leather, chair of the Charity Commission
-    Sir Derek Wanless, author of Securing our Future Health (2002) and Our Future Health Secured? (2007)
-    Sir Ronald De Witt, chief executive of Her Majesty’s Courts Service and executive director of the Department of Constitutional Affairs corporate board
-    Professor Mala Rao, RSPH Ambassador to India
-    Dr Fiona Adshead, Deputy Chief Medical Officer
-    Dr Linda Degutis, president, American Public Health Association
-    Dr Georges Benjamin, chief executive, American Public Health Association

Hazel Stuteley OBE introduced herself as a ‘Sir Derek Groupie’, resulting in the first of many laughs during her presentation. And between the jokes, Hazel gave us a number of very serious messages. She reminded us of the famous Mary Mead quotation, ‘never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has’.

Hazel told us of how a small group of thoughtful committed citizens in England’s poorest County (Cornwall) did just that ……. in Falmouth. In a true example of multiagency working (health, police, education), significant reductions were achieved in asthma, teenage pregnancies and postnatal depression. There were big improvements in child protection. This and much more was achieved with excellent value for money too – less than 50 pence a day, for each resident.

The Royal Society for Public Health is the result of a merger between the Royal Society of Health and the Royal Institute of Public Health. Membership of the new Royal Society includes professionals from health protection, environmental health, the health professions including medicine, health & safety, food hygiene, nutrition, health promotion, teaching, research, social care and more.

Click here and here for more details of the launch

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11/07/2008 by Patrick Keady.

I was interviewed for the NHS60 celebrations that took place at Wembley Stadium on 1st July. The NHS60 - 1990’s - Managers interview was one of six, that were broadcast on Sky 168, as part of  the NHS Live Annual Conference. The six interviews were rebroadcast on Sky 167 in the days following the Conference. They are now streaming on the Department of Health YouTube channel. You can see the individual interviews by clicking on the appropriate link:

• 1940s - Before the NHS - Roy McIaney, John Taverner
• 1950s - Children - John Taverner
• 1960s - Nursing - Marie Jaswal, Olwen Al Bermani
• 1970s - GPs - Dr Pravin Shah
• 1980s - Paramedics - Doug Wisener, Dr Mohammed Akhtar
• 1990s - Managers - Patrick Keady, Olwen Al Bermani

Posted in Gas Street Works, Darzi, David Nicholson, Patrick Keady, Wembley, Safety, Patient, Governance, NHS, Health and | Print | No Comments »

29/06/2008 by Patrick Keady.

The NHS is 60 on Tuesday. Happy birthday to a British treasure that is respected at home and around the world.

And tomorrow, Lord Darzi publishes his views on how the NHS can enhance that respect by delivering even better healthcare over the next 10 years. Further changes in NHS strategy are quaranteed. And as we know, implementing strategies can be challenging. Which reminds me of a research paper that I read recently. Based on the views of 35,000 people, the paper highlights just four areas that make (or break) the effective implementation of strategies.

My view is that by focusing on these four areas, professional groups, SHAs, PCTs and Trusts will be well placed to respond to Lord Darzi’s challenges. The four areas are information, decisions, motivators and structure. Here’s my initial thoughts on how NHS organisations and people working with NHS patients, can be better placed to deliver even better healthcare over the next 10 years.

Information - that important ‘competitive’ information gets to Boards, PCTs, SHAs and the Department of Health, more quickly – from patients, staff, independent healthcare providers, charities. That information flows freely across professional and organisational boundaries. NHS employees and other people employed to work with NHS patients, understand the real impact of their day-to-day choices on patients. Middle managers and clinicians have access to the information that they need to measure the key drivers of their service. That sources of conflict are acknowledged and responded to appropriately.

Decisions - reducing uncertainty will ensure that all people working with NHS Patients, understand the decisions and actions that they are responsible for. People will be clear about the impact of their decisions. They will be happy to be held accountable. Senior clinicians and managers will continue get involved in decisions at speciality/Departmental levels. The culture moves further towards ‘persuade and cajole’ and away from ‘command and control’. Human Resources, Finance and other corporate roles further change their behaviour to support Specialities and Departments.

Motivation is the third driver. Performance will focus more on outcomes – differentiating between high, adequate and low performers. Career advancement and salaries will be strongly influenced by the individual’s ability to deliver on their performance commitments. Even when an NHS organisation has a bad year, and one of its Specialities or Departments has a good year, the Speciality/Departmental gets a bonus – the team earns greater autonomy and financial support to further develop their Speciality/Department.

Structure. Increasingly, promotions will be from one position to another on the same level in the hierarchy. Fast-track employees can expect to be promoted upwards, at least every three years. Middle managers have a minimum of five direct reports.

So there you have it - my thoughts on four drivers that will help translate Dr Darzi’s thoughts into reality. Having worked with the NHS for 17 years, I know that we have the ability to achieve this. My gut-feel is that we will exceed! Here’s to even better NHS outcomes over the next 10 years.

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11/06/2008 by Patrick Keady.

I was interviewed today. About what it was like to be an NHS manager in the 1990’s.

The interview was recorded. With just one day’s notice, preparing for the interview, was interesting. While I knew that there would be three people in the studio – interviewer, cameraman and me - I was aware that a lot more people were likely to see the video. This is when I thought …… oops, gulp, do I really want to participate in the interview! So I realised that I needed a plan. But what might it look like? Well after some thought, these are the actions that I came up with:

1. looking at the interviewer, not on the camera
2. dressing in NHS manager uniform ….. the suit
3. being aware of my posture
4. speaking more slowly than usual, so that I had more time to fully express my thoughts
5. predicting the likely questions that I might be asked
6. identifying the key messages that I wanted to get across about what it was like when I was an NHS manager in the 1990s
7. switching the mobile phone off, removing coins from my pockets and asking that the TV screen set was switched off, so that I could not see myself being interviewed
8. having examples prepared, so that my messages were personal to me
9. expecting the unexpected, flexibility would be a bonus
10. being an active participant - because the camera (and audience) would see everything - posture, energy, facial expression
11. taking a brisk walk beforehand - to get the adrenaline flowing

So did the plan work? While I haven’t seen the video, I was happy with how the interview was managed by the interviewer and cameraman. These guys clearly knew what they were doing. I will post a link on this blog, after the interview is broadcast.

Posted in Wembley, Gas Street Works, Patrick Keady, Safety, NHS, Health and, Patient, Governance, Personal Development | Print | No Comments »

23/05/2008 by Patrick Keady.

Josephine Ocloo

Krista Ocloo, was born in 1979. Her congenital cardiac abnormality was successfully repaired at an NHS Hospital, shortly before Krista’s second birthday. She went on to enjoy a happy and normal childhood and early teen years. But in 1995, Krista started to complain of chest pain. In January 1996, she was admitted to the same NHS Trust for an exploratory catheterisation.

Krista’s mum, Josephine, was assured by the NHS, that Krista was perfectly all right and that an appointment would be booked for another check-up. Krista was discharged but the appointment was not scheduled until January 1997.

On 5th December 1996, Josephine found Krista at home in bed …….. Krista was dead. The post-mortem revealed death from acute heart failure.

Josephine Ocloo, relayed her story to the 600 delegates at today’s Patient Safety Congress. The Nursing Director next to me, stopped taking notes. She placed her notebook on the floor and gave her undivided attention to Josephine Ocloo. Josephine then described how she tried to get answers from the NHS Trust. Josephine wanted to know why Krista had died. SheJosephine described an NHS that was at best, unhelpful. Around me, I saw some tears, I heard lots of sniffles …… and there was very little note-taking.

Krista died before the introduction of Clinical Governance, the Turnbull Report, Choice and Competition as we know it today. But what can today’s NHS do to ensure that all of today’s patients get a better service than Krista received 12 years ago? Professor Bernard Crump (Chief Executive of the NHS Institute for Innovation and Improvement) asked delegates for their thoughts. He asked them to identify which one of the following can best improve patient safety

1. Regulation and Standards
2. Commissioning, Competition and Choice
3. the personal motivation of NHS professionals, leadership

David Nicholson, Chief Executive of NHS England, told us that delegates and the NHS in general, needs to be clear about the services that we want to deliver for patients. He added that techniques such as PDSA, Lean etc, together with new behaviours, will help.

Don Berwick, President and CEO of the Institution for Healthcare Improvement, added that improving healthcare needs to be embraced in every hospital, by every GP practice and by all healthcare professionals. Professor Cecil Helman alerted us that the definition of health, continues to change. Since the NHS was established in 1948, the definition of health has fragmented into physical, psychological, social and spiritual. David Dalton Chief Executive at the Salford Royal NHS Foundation Trust, joked that his organisation was ‘crap at implementation’. He then added that his Trust reduced Clostridium Difficile infection rates by 70% in 10 months. The Trust achieved this by empowering staff to identify the problems that they wanted to deal with, and giving them the necessary support. Sir Liam Donaldson, Chief Medical Officer, suggested that in 2018, infection prevention might be achieved with the help of sensors, that there might be voice operated electronic prescribing, checklists in surgery and an aviation-style ‘black-box’ in operating theatres. Peter Walsh, Chief Executive of Action against Medical Accidents, pointed out that NPSA Being Open, is only guidance. He urged for a major uptake of training in NPSA Being Open. Rashmi Shukla highlighted the characteristics of a safe system. Eamonn Kelly identified how World-Class Commissioning, the Assurance Framework and the Standard Contract for Acute Services can improve services. Katherine Fenton challenged the role of Strategic Health Authorities, adding that it needs to shift towards motivating their PCTs and Trust improve. Sarah Andrews added that while NHS targets can be useful, the NHS will benefit from celebrating it’s achievements. Gerry Marr from NHS Tayside highlighted how data owned by Clinicians is being used to show decreases in Hospital Acquired Infections. Data from Clinicians in Tayside, will be used to confirm a 15% reduction in mortality and a 30% reduction in adverse events. Martin Fletcher, Chief Executive of the National Patient Safety Agency highlighted Royal Gwent where there is a 95% compliance with hand hygiene, more than twice the average compliance of 40% in England and Wales. This high level of compliance was achieved because of strong leadership, the use of an effective implementation tool, the measurement of outcomes and providing feedback to staff. To be a Regulator or not to be a Regulator, that was the question! Paul Philip (General Medical Council), Sarah Thewlis (Nursing and Midwifery Council), Gary Needle (Healthcare Commission) and Simon Gregor (Medicines and Healthcare products Regulatory Agency) were all proud of their roles as Regulators. But Professor Bruce Campbell (National Institute for Health and Clinical Excellence) and Professor Dame Joan Higgins (NHS Litigation Authority) emphasised that their Organisations were not Regulators.

And what responses did delegates give to Professor Bernard Crump’s poll? 3% of Delegates voted regulation and standards as the most effective approach to improving Patient Safety. 2% went for Commissioning, competition and choice. The other 95% opted for the personal motivation of NHS professionals and effective leadership.

Is it a coincidence that in the 12 years since Krista’s death, we have seen a plethora of activity in the areas that received the fewest votes? – regulation, standards, commissioning, competition and choice.

It is refreshing that based on the messages from these speakers, that effective leadership and the motivation of staff is leading to dramatic improvements in parts of the NHS.

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22/05/2008 by Patrick Keady.

In my last contribution (18th May), I concluded that an important challenge for all NHS organisations, is to continue motivating and acknowledging the successes of their employees. But I didn’t suggest how Organisations can make this a reality.

Today I saw an excellent example of how NHS Organisations can do just that. I was one of 600 delegates at the 2008 Patient Safety Congress. An impressive contribution came from a speaker not listed on the programme, the Prime Minister, Gordon Brown.

He acknowledged that NHS staff and partners are not thanked enough for their commitment to patients. Mr Brown reminded us that NHS staff are the pride of the UK. He shared with us how the NHS cared for him , following a rugby injury, sustained at the age of 16. He told us that he was grateful for everything we do. A Consultant Anaesthetist in the audience put his hand up to his eye. The Chief Executive sitting in front of me, cleared this throat.

Mr Brown’s short visit was was unexpected. But his contribution was effective because he acknowledged the commitment of NHS staff and he shared some of his personal experiences with us. Click here to see Mr Brown’s address to the Patient Safety Congress 2008.

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06/04/2008 by Patrick Keady.

To download this article, click Summary of the Act

Here you will find a summary of the Act of Parliament that came into force today, 6th April 2008. Those who disregard the safety of patients, workers, visitors and others with fatal consequences, are more vulnerable to serious criminal charges: Corporate Manslaughter (in England, Wales and Northern Ireland) and Corporate Homicide (in Scotland). Examples are given of some of the actions that NHS organisations can take, to protect themselves from unlimited fines, publicity orders, remedial orders. Taking these actions will also help you to reduce the risk of making career-limiting decisions.

The lack of convictions resulting from these 276 deaths, contributed to the introduction of The Corporate Manslaughter and Corporate Homicide Act 2007: Herald of Free Enterprise (1987), 193 deaths. The Sheen Report criticised the P&O attitude to safety, asserting that ‘….from top to bottom the body corporate was infected with the disease of sloppiness….’. Kings Cross Fire (1987), 31 deaths. Southall train crash (1997), 7 deaths. Ladbroke Grove rail crash (1999), 31 deaths. Hatfield rail crash (2000), 4 deaths.

It applies to all NHS organisations, Arms Length Bodies, Independent Healthcare organisations and a wide range of other organisations including partnership employers (trade unions and employers’ associations), Government Departments and Police Forces.

The Act sets out a new offence for convicting organisations where there was a gross failure in how activities were managed or organised. Organisations will be guilty of the new offence if the way in which their activities are managed or organised:
• cause death and
• amount to a gross breach of a duty of care owed to the deceased.

This will arise where the organisation’s conduct falls far below what could have been reasonably expected. While ‘far below’ has yet to be defined in the Courts, Juries are likely to take into account, breaches of legislation and guidance: Health and Safety at Work etc Act 1974, Management of Health and Safety at Work Regulations 1999 and HS(G)65: Successful Health and Safety Management. They will also take into the following into account: how serious and dangerous the failures were, the risk of death posed; admissible expert evidence; patient and occupational safety & health guidance relevant to the breach; those attitudes, policies and systems demonstrating the acceptable practices in the organisation that were likely to encourage a lack of compliance with the above.

A duty of care exists for example, in respect to the systems of work and equipment used by employees, the condition of workplaces, other premises and in relation to products or services supplied to patients. The Corporate Manslaugher/Homicide offence is based on existing duties, already owed in the civil law of negligence.

• 84,000 – the number of patient safety incidents reported to the National Patient Safety Agency, resulting in some degree of harm to NHS England inpatients in 2006/07
• 2,000 – The National Audit Office reported that 2,000 patient deaths a year are attributable to negligence. It is unclear if any of these deaths result from gross failure in the management and organisation of care and other activities

It has been suggested that had the following four events occurred after 6th April 2008, that the relevant NHS organisation could have been charged with Corporate Manslaughter:
• NHS Trust (a) - 90 patients died from Clostridium Difficile.
• NHS Trust (b) – 1 patient died from an air embolism
• NHS Trust (c) – 1 patient tore a ligament and was treated successfully, then contracted MRSA and died.
• Window Restrictors – between April 2002 and March 2004, seven people died following a fall from, or jumping from the windows of NHS buildings. The Window restrictors were missing in all seven cases.

Courts will look at management systems and practices across the organisation, with a view to finding an effective means of prosecuting the worst corporate failures in managing patient and occupational safety & health. This introduction of this Act of Parliament, is an opportunity for employers to reconsider how risks are managed. Organisations are advised to ensure that they are taking proper steps to meet the legal duties referred to above in ‘Gross failure’.

Juries will consider how the fatal activity was managed or organised, including the systems and processes for managing safety and how these were operated in practice. A substantial part of the failure within the organisation will have been at a senior level. Senior level refers to those who make significant decisions about the organisation or substantial parts of it. These include headquarters functions and operational management roles. Consultant Doctors and GP Practices (but not individual GPs) might also be considered senior level.

Prior to 6th April 2008, health & safety investigations were usually lead by the Health and Safety Executive. However, all Corporate Manslaughter investigations will be lead by the Police. While NHS benchmarking successes (including the Annual Health Check) are essential in today’s NHS, it is unlikely that they will be relevant in the event of a Corporate Manslaughter investigation. For an overview of what will be relevant, check out ‘Gross failure?’ above.

An organisation guilty of the offence will be liable to an unlimited fine. The Act provides for the Courts to impose a publicity order, requiring the organisation to publicise details of its conviction and fine. This will be commenced at a later date, when sentencing guidelines are available in autumn 2008. Courts may also require an organisation to take steps to address failures behind the death (a remedial order).

Not under this Act - it is the organisation itself that will face prosecution. However, please note that since 1975, individuals can be prosecuted for gross negligence manslaughter/culpable homicide and for health and safety offences – under the Health and Safety at Work etc Act 1974. Prosecutions against individuals will continue to be taken where there is sufficient evidence and it is in the public interest to do so. As patient safety and occupational safety & health continue to move up the Corporate agenda, these prosecutions will probably be career-limiting too.

Failures by senior managers to successfully manage patient safety and occupational safety & health, will leave organisations vulnerable to charges of corporate manslaughter. Senior managers are advised to ensure that they and their organisation comply with current patient safety and occupational safety & health requirements. The Institute of Directors and the Health and Safety Commission has produced guidance entitled “Leading health and safety at work – Leadership Actions for Directors and Board Members” http://www.hse.gov.uk/pubns/indg417.pdf

Employers have a legal duty (RIDDOR) to report certain incidents at work, including work-related deaths. Where a criminal offence is suspected, the police will lead the investigation and work in partnership with the Health and Safety Executive, local authorities and other regulatory authorities.

While the Government expects that cases of corporate manslaughter/homicide following deaths, will be rare, here are examples of questions that NHS Organisations might want to reconsider today, to ensure that their patient and occupational safety & health culture continues to perform well in the future, and under increased scrutiny. Objective and subjective evidence will be crucial.

Who is responsible, from the Board through to Specialities? Which individuals are in the ‘senior level’? Do they understand their responsibilities? Are policies practical, audited and reviewed? Risk assessments are up-to-date? How do you notify staff of changes in policy? How are near-misses reviewed? Do you implement recommendations from SUI reviews, root cause analyses, investigations and Inquiries? Breaches, how does the organisation respond? Are minutes from these meetings actioned - Board and Committees, including Governance, Risk Management, Occupational Safety and Health, Patient Safety, Workforce, Clinical Effectiveness? Are emails and other correspondence reviewed? Are staff supervised effectively? 100% of staff are appraised regularly? How are underperforming staff managed? Are staff trained about policies and associated record-keeping?

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