Quality and patient safety

Since November 2014, NHS providers have been required to comply with the statutory duty of candour (it has applied to all healthcare providers since 1 April 2015). This means that providers must be open and transparent with service users about their care and treatment, including when it goes wrong. The duty of candour regulations also impose a more specific and detailed duty of candour on all providers where the level of harm is above a specified harm threshold. 

The introduction of the statutory duty of candour implemented a key recommendation of the Mid Staffordshire NHS Foundation Trust Public Inquiry (the “Francis Inquiry”). There already existed a contractual duty of candour, which had been imposed on NHS providers by way of the NHS Standard Contract with Commissioners since April 2013.

This policy is followed by all trust staff. Email rf.seriousincidents@nhs.net to receive a copy of the trust's duty of candor policy.

The Trust is committed to delivering care and services that are safe, effective, caring, responsive and well-led. Promoting a culture of openness and transparency at all levels is a prerequisite to improving the delivery of services for patients. Staff at the Trust must therefore promote an open and honest culture in all disciplines and at all levels.

Occasionally a patient suffers or experiences harm as a result of a safety event. The Trust has a statutory and contractual duty of candour to take specific action if the harm is above certain thresholds. This policy sets out what action should be taken when a “notifiable safety event” occurs.

Only through reporting and analysing such safety events can the organisation learn and prevent recurrence in the future. By incorporating and integrating openness and honesty within clinical practice and risk management processes, we can embed lessons and change practice, processes and systems.

Responsibility of the trust board

The Trust Board has made public commitments to implementing a policy of candour and is accountable for ensuring the duty of candour is met. The chief executive officer (CEO) has overall accountability for patient, staff and public safety and for promoting an open and fair culture and to facilitate the reporting, investigation and learning from safety events and providing assurance to the Board.

The CEO delegates responsibility for ensuring there are appropriate processes in place for the management of safety events through the group chief nursing officer. The chair of the trust board is responsible for providing scrutiny and challenge to the assurances given by the CEO. The trust quality group (TQG) is the sub board responsible forum.

The group chief nurse (responsible for patient safety and risk) is responsible for ensuring the duty of candour is met when it is identified that a patient has been involved in a notifiable safety events. The chief medical officer is responsible for ensuring the duty of candour is met when it is identified during the complaint’s procedure that a patient has been involved in a notifiable safety events.

Responsibility of the Trust Quality Group (TQG)

This committee is responsible for monitoring compliance of duty of candour across the Trust.

Responsibility of the Hospital Clinical Performance and Patient Safety Committees (CPPSCs)

These committees are responsible for overseeing delivery of the duty of candour and are expected to support and challenge the information provided, to ensure the duty of candour is implemented throughout the Trust.

Responsibility of the Divisional Quality and Safety Boards

The Divisional boards are responsible for ensuring duty of candour is implemented within their divisions.

Responsibility of the patient safety incident response panels (PSIRP)

These panels are responsible for monitoring implementation of the duty of candour in the investigation of safety events.

Responsibility of registered healthcare professionals (including doctors, nurses and allied health professionals)

Registered healthcare professionals are expected to play a major role in supporting the Trust’s duty of candour to patients, and doctors and nurses in particular will often have the duty of candour conversation with patients.

Registered healthcare professionals additionally owe a professional duty of care to their patients, as set out in the Joint Statement from the Chief Executives of statutory regulators of healthcare professionals on the Professional Duty of Candour.

This places an obligation on registered healthcare professionals to be open and honest with patients when something goes wrong with their treatment causing any level of harm and/or distress. This includes giving the patient an apology and a full and prompt explanation, setting out what has happened and explaining the short and long-term effects.

Responsibility of business unit and divisional quality governance teams

Quality Governance Teams are expected to support patients, their families and staff involved in safety events and to ensure the Trust acts in an open and transparent way. This will include:

• liaising with the treating team to ensure the patient/relevant person receives a clear and comprehensive explanation of what has happened and to check that the duty of candour conversation has taken place and has been appropriately documented in the patient’s medical records;
• ensuring that the duty of candour letter is sent to the patient/relevant person;
• keeping the patient/relevant person informed about progress of the investigation and offering a copy of the final investigation report;
• ensuring that the duty of candour sections of the Datix safety event records are completed, including ensuring that relevant duty of candour evidence (including a copy of the duty of candour letter) is attached to the Datix safety event record.

All staff

All staff are required to report and record that a patient has suffered harm in line with the safety event reporting policy. They must ensure that their manager has accurate and comprehensive information to enable them to take appropriate actions.

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. 

It ensures health and social care services provide people with safe, effective, compassionate, high-quality care and encourages services to improve.

The CQC monitors, inspects and regulates services to make sure they meet fundamental standards of quality and safety and publish what they find, including performance ratings to help people choose where they have their care. 

Trusts are rated as either outstanding, good, requires improvement or inadequate. 

The last time the Royal Free London was inspected (11 December 2018 to 10 January 2019), significant areas of good and outstanding practice was identified despite a fall in our overall rating to 'requires improvement'. 

We received three ‘good’ ratings for being effective, caring and well-led. 

Inspectors found that services were safe and responsive, however, they said improvements were required in these areas. 

Our ambition is to move to ‘outstanding’ and we undertake quarterly CQC self-assessments to ensure standards are being met across services and sites. 

Individual hospital ratings

We are committed to delivering care and services that are safe, effective, caring, responsive and well-led. 

Hundreds of patients come through our doors daily. Most receive treatment, get better and can return home or go to other care settings. We do all we can to deliver harm-free care for every patient, every time they are seen.  

However, healthcare does carry some risk and while everyone in the NHS works hard every day to reduce this risk, harm still happens. 

When harm occurs and results in a patient safety event, we respond quickly to understand what has led to the harm and where necessary, put improvements in place.

As part of a national initiative, we are implementing the Patient Safety Incident Response Framework (PSIRF), which will replace the Serious Incident framework (2015). This will assist us in learning from patient safety events when they occur. 

The main principles of PSIRF are:

• compassionate engagement and involvement of those affected by patient safety events 
• application of a range of system-based approaches to learning from patient safety events 
• considered and proportionate responses to patient safety events and safety issues 
• supportive oversight focused on strengthening response system functioning and improvement

Understanding our safety profile

Our trust has a continuous commitment to learning from patient safety events and we have developed our understanding and insights into patient safety matters over a period of years.

The patient safety team has engaged with key stakeholders, both internal and external, and reviewed data from various sources to arrive at a trust safety profile. 

This process has also helped us to identify the methods we will be using to maximise learning and improvement. We have captured this in our PSIRF policy which we will publish shortly. 

Engaging with those affected by patient safety events

We recognise that learning and improvement following a patient safety event can only be achieved if supportive systems and processes are in place for those who have been involved, including patients, families and staff. 

Patients and families often provide a unique, or different perspective to the circumstances around patient safety events and may have different questions or needs to that of the organisation. 

We also know from evidence that when patients are treated as partners in their care, significant gains are made in safety, patient satisfaction and health outcomes. 

By becoming active members of the healthcare team, patients, carers and communities can contribute to the safety of their care and that of the health care system as a whole.

This helps us to:

• be more open and transparent on learning
• understand the actual safety experience of our patients and what makes them feel unsafe
• make improvements

We are committed to involving patients and families in our safety work. 

Our patient safety partners and patient representatives are supporting our work to strengthen our processes to provide compassionate engagement and to involve more patients improving the safety of their care and that of the trust as a whole. 

Patient safety documents

• Read our patient safety incident response policy
• Read our patient safety incident response plan

We take several steps to ensure we follow robust safeguarding procedures for children at each of our hospitals. 

Every member of hospital staff employed by the trust understands they have a responsibility to safeguard children and they are supported by the named doctor and nurse in doing this. 

We follow the guidance in the London child protection procedures and work closely with multi-disciplinary colleagues.

The safeguarding procedures in place for vulnerable children include: 

• a proactive safeguarding children team
• flagging systems for children subject to child protection plans
• a robust child protection training schedule
• written updates for all hospital staff on safeguarding procedures and issues
• participation in multi-agency audits and active participation in local safeguarding children boards and related groups 

If concerns are raised about a child, we need to investigate this fully and a skeletal survey may be carried out to check for signs of injury or an underlying medical condition. 

Find out more about skeletal surveys in children. 

The safeguarding children team can be contacted by email rf-tr.safeguardingteam@nhs.net or telephone 020 8216 4158 or 020 8216 5419