Director of Corporate ServicesReport
Author:Keith Cox, Board Secretary/Director of Corporate Services
Date:06 February 2013 / Version:1
Publication/ Distribution (on completion):
- Executive Team
- Public Health Wales Intranet
- Public Health Wales Internet
Purpose and Summary of Document:
The purpose of this paper is to provide the Boardwith a report on Public Health Wales’ key governance issues, which includes corporate, incidences and concerns
Date: 06 February 2013 / Version: 1 / Page: 1 of 9
Public Health Wales / Director of Corporate Services Report
1 Corporate
1.1Policies
The following policies were approved at the recent Quality and Safety Committee meeting:
- Medicines Management policy
- Infection Control policy
- Decontamination policy
- Radiation protection policy
The following policies are currently out for consultation:
- Policy and Procedure for the Receipt and Dissemination of Alerts / Safety Notices
- Standard Infection Control precautions policy
- Lease Car scheme
- Claims Management procedure
- Home working policy
The following policies have recently been developed and will shortly be available for consultation:
- Incident reporting policy
- Environmental cleanliness policy
1.2Claims
1.2.1Clinical negligence and personal injury claims
Public Health Wales currently has 13 open cases (clinical negligence and personal injury claims only).
1.2.2Damage to property claim
A shadow claims panel was recently established to consider a claim for damage to personal property belonging to a member of staff. A second claim from another member of staff has been received and is due to be considered by the shadow claims panel once further information on the claim has been received.
1.3Service Level Agreement
Work is ongoing to organise delivery of services which will no longer be provided by Velindre NHS Trust.
Service leads within Public Health Wales are currently working to ensure a smooth transition and projects to cover the Financial Services and DATIX elements of the SLA have been established.
The first meeting for the DATIX project took place at the beginning of January and the second project meeting is due to take place on 1 February.
Discussions are still taking place with Velindre in relation to the delivery of the following services; research and development, claims management and fire safety. It has been agreed that Public Health Wales will continue to receive a similar level of support in these areas during 2013-14, with the exception of claims management. The claims management service will be delivered in-house, but Velindre will provide training and support to enable Public Health Wales to meet its legal responsibilities.
Work is currently being undertaken to bring the claims service in-house. A Claims policy and procedure has been developed in order to satisfy the requirements of the Welsh Risk Pool. It is essential that these are in place by the end of March 2013.
2DATIX Installation Project
A PID has been developed to manage the installation of the system and it’s hosting by NWIS and a Project Team has been established. It is proposed for the Project Team to meet every two weeks to ensure the delivery of the identified projects. Sub groups have also been established to review specific coding that fits to the needs of the organisation and this work has commenced.
A phased approach has been adopted for implementation of the modules, which with the exception of the FOI module, will be web based. The risk and incident modules will be implemented by the 1 April 2013 and the claims, complaints and FOI by the 1 May 2013.
It is also intended to take a copy of the current Public Health Wales information held on the Velindre system which will then be archived but still available within the new system.
To enable a copy of all Public Health Wales information currently held on the Velindre DATIX system to be taken, divisions will be required to stop using the all DATIX modules from the 15 March 2013. From this date divisions will need to complete paper forms to report incidents, along with maintaining a spreadsheet for risks, complaints and claims. To assist divisions, teams and laboratories with this a template incident form and spreadsheet will be made available.
Prior to this cut off date divisions / teams / laboratories will also need to ensure that, if possible, all incidents and complaint are closed.
3Putting Things Right Report (Incidents, Complaints and Claims)
3.1Incidents
A total of 262 incidents were reported in Quarter 3 compared with 218 from the previous quarter. The data demonstrates an increase in the number of incidents against the previous quarter. The report does not include the errors reported by the Microbiology Division which are currently being reviewed and some may be re-categorised as incidents. The overall total of incidents may therefore increase.
A total of 137 were graded for risk as detailed below and 125 are awaiting review:
33 / Low88 / Mod
15 / Sign
1 / Crit
Quarter 3 incidents by type:
The highest percentage of incident type reported for the quarter was Patient/Client, totalling 40% of the overall incidents.
Breakdown by Service Area
3.1.1Clinical Incidents:
Potential SI WEB429080 (ID: 35415)
A BSW participant underwent a surgery following a significant life threatening bleed after receiving a colonoscopy. An investigation into the incident has commenced.
3.1.2Health and Safety Incidents
Listed below are a number of examples of significant Health and Safety incidents.
WEB427577 (ID: 33893)
Following a power failure at Mamhilad it was discovered that half of the main circuit board had melted. An electrician has replaced the circuit board.
WEB427852 (ID: 34172)
Following a building fire drill staff we asked to return to the building. One staff member was in lift 5 with other colleagues from the building when the lift suddenly dropped from floor 7 to floor 3. Staff were badly shaken but no injuries were sustained.
Incident reported to building manager.
WEB427940 (ID: 34261)
Large water leak from the ceiling space in the main corridor. Debris and water found on the floor by the laboratory manager.
Corridor closed off and Estates notified. The Asbestos incident team attended site and the affected site was isolated and decontaminated and contaminated laboratory coats located in the corridors were removed for safe disposal. Monitoring and testing carried out by Asbestos assessor. The repair work has been carried out to damaged steam and water pipes and was monitored by the Asbestos Team. Air inspection records are available.
WEB428234 (ID: 34555)
Some staff became unwell following attendance at a Safeguarding Children team monthly meeting where a buffet lunch from an outside caterer was provided. The Environmental Health Dept. in Cardiff has been notified and are currently investigating the incident.
Note: One of the five other colleagues affected by the incident is an external, non-PHW, individual (independent contractor) who briefly visited the meeting and took lunch.
WEB428930 (ID: 35261)
Refurbishment was carried out on a room which required the laying of cement to level the floor. A notice was only placed on the door only but the area was not cordoned off. A member of staff member entered room and slipped through wet concrete resulting in a leg injury and damage to clothing.
3.1.3Operational & Organisational Incidents
WEB428284 (ID: 34609)
An incident of Virus infection on a number of computers and servers. Full Virus Scan Activated with success.
All staff reminded of the importance of following the guidelines for internet and e-mail use, and the use of external storage media (flash drives, pen drives etc).
3.2Claims
3.2.1Claims Profile
The claims profile for the Public Health Wales is detailed in the table below:
Cumulative Number of Ongoing Claims / 13Number of New Claims this Period / 1
Number of Settled Claims this Quarter (costs outstanding) / 0
Number of claims closed this Quarter and all costs paid / 0
Number of Withdrawn Cases this Quarter / 2
Aggregate Value of Claims in Progress / £3,220,273
Number of Claims that have arisen from an Incident / 12
Anticipated Public Health Wales Liability in respect of claims / £233,200
Anticipated Welsh Risk Pool Liability in respect of claims / £2,987,073
3.2.2New Claim
The new claim relates to damages resulting from with failings in claimants care in relation to oncology results, colposcopic management and clinical administration.
It is alleged that two opportunities where treatment could have prevented cancer were not acted upon by the clinic.
This claim relates to SI WG Ref: 326929November11.
3.2.3Closed Claims
Two following two claims were closed during quarter 3
CHQ-CM-0100 / Alleged failure to act upon blood test results causing a delay in diagnosis of MRSA. / 28/11/2012 / Settled by HB no proceeding pursued against PHW.CHQ-CM-0084-H&S / L&RS to Bill and Close as no letter of claim received as at 9/12.
Request for Personnel and Occupational Health Records - RSI Injury to Thumb. / 20/11/2012 / No letter of claim received.
3.3Complaints
A total of 9 complaints were received in quarter 3. Of these, 2 complaints were received by both Cervical Screening Wales and Bowel Screening Wales, the rest were received by Breast Test Wales.
Of these, 3 complaints have been closed and 4 are ongoing pending further investigation.
4Estates
The new Facilities Manager, Nicola White, commenced employment with Public Health Wales on 2 January. Over the past few weeks the Facilities Manager has completed essential training and attended a number of introductory meetings with Public Health Wales Directors and Managers. In addition to this, the Facilities Manager has attended meetings with Shared Services Fire Advisors, Charted Surveyors and Santia Risk Management Services.
Some key areas identified as priorities for the Facilities Manager over the next few weeks include visibility of the Asbestos Register, the Contractor Management System and a Pre-Qualifying Questionnaire for contracting companies. The latter will ensure that contractors working on behalf of ourselves or on behalf of the landlord are competent and will not expose themselves or Public Health Wales staff to potential hazards.
An accommodation review is underway at St David’s Park, Carmarthen.
The new Facilities Manager will be visiting Public Health teams in North Wales at the beginning of February.
5Asbestos
5.1Asbestos Policy
The Asbestos Policy has been approved.
5.2Asbestos training
Once the new facilities manager is in post and the appropriate regional support structures are in place, Santia will host a training session for these staff to show how the new web based Asbestos Risk Assessments can be accessed and reports created.
6Fire Safety Managers report
The Fire Safety Policy has been reviewed by the Facilities Manager and the Fire Safety Advisor. Dates have also been scheduled in February and March to undertake fire audits on the Temple of Peace, Mamhilad House and St David’s Park, Carmarthen to satisfy the requirements of the FSN Fire Safety Audit System.
There were no reported Fire incidents in this period.
6.1Training
Fire Safety training was delivered to staff at Magdem Park, Llantrisant on 16 January 2013.
7Health and Safety
The Health and Safety Lead for Public Health Wales has continued to support the Workboost team on a number of initiatives for SME businesses that are engaged with the Workboost service. Stakeholder partners include HSE, ACAS, Care Forum, Federation of Small Businesses, Remploy, Deeside College and Vale of Glamorgan Council. Stop Smoking Wales and 1,000 Lives teams are also engaged with the initiatives.
The Health and Safety workgroup have contributed comments to the Professional and Organisational Development team for the review on statutory and mandatory training. The workgroup have also contributed comments to the projected work action plan for the Health and Safety lead.
The Health and Safety lead has also provided advise and is following through various incidents from across the organisation. Any matters of concern will be reported separately.
Date: 06 February 2013 / Version: 1 / Page: 1 of 9