HSE Safety and Quality Committee meeting minutes 16 June 2023

Committee Members Present

Prof Deirdre Madden (Chair), Dr. Cathal O’Keeffe, Dr. Yvonne Traynor, Prof. Fergus O’Kelly, Mary Culliton, Jacqui Browne, Margaret Murphy, Anne Carrigy

HSE Executive Attendance

Dr. Colm Henry (Chief Clinical Officer), Dr. Orla Healy (ND QPS), Martina Queally (Chief Officer Community Healthcare East), Niamh Drew (Deputy Corporate Secretary), June Robinson (Office of the Board), Sharon Hayden (Manager Office of the Chief Clinical Officer), James McGrath (CEO Office)

Apologies

Dr. Anne Kilgallen

Joined the meeting

Dr. Philip Crowley (National Director Strategy and Research), Miin Alikhan (AND National Strategic Planning and Reporting), Dr. Gemma Moore, Alison Lynch, Kilian McGrane (National Programme Director, National Women and Infants Health Programme), Dr. Cliona Murphy (Clinical Director of the National Women and Infants Health Programme), Dr. Peter Mc Kenna (Clinical Lead, Obstetric Events Support Team), Fiona Murphy (Chief Executive, Screening Service), Patrick Lynch (National Director Governance and Risk)

Minutes reflect the order in which items were considered and are numbered in accordance with the original agenda.

1.1 Welcome and Introductions

The Chair welcomed the Committee members to the meeting.

The Committee held a private session where the Chair provided a summary of the agenda and the relevant papers and outlined the approach that would be taken to conducting the meeting. She noted that the focus of the meeting would be to receive updates on key items and to suggest relevant actions as they became apparent.

2.1 Declarations of Interest

No declarations of interest were made.

2.2 Minutes

Minutes of 25th April were approved subject to an amendment.

Minutes of 19th May were approved subject to an amendment.

The Committee was provided with an overview of the process and indicative timeline for the development of NSP 2024, highlighting three features supporting the development of the plan. This included strong direction from the Board, content to be more focused on multi-annual delivery commitments and a guidance document which will have a national planning framework with clear direction.

The Committee welcomed the update and sought further information regarding how the safety and quality theme is integrated into the planning process across all services. The Committee also requested that the plan should clearly show what specific quality improvements are expected in areas such as Disabilities and Older People.

The Committee discussed progressing developments with regards to eHealth records, noting that a lack of integrated systems continues to cause delays and issues in the system. They highlighted that, if addressed, this would support the progression of the patient through the system in a timelier manner.

It was agreed that a further and more focused discussion on NSP 2024 will be an agenda item for the Committee’s September meeting.

Ms. Lynch shared her experiences across her two pregnancy journeys detailing aspects of maternity care and reproductive health, including her experience of IVF, genetic testing, diagnosis and management of fatal foetal abnormality, termination of pregnancy, bereavement services and follow up supports received. Her key recommendations made to the Committee were that there should be a standard bereavement pack provided for mothers/ parents, improved training of staff to support bereaved parents in dealing with sensitive cases and the continued development of genetics research.

The Committee discussed how to support this type of service not just at the acute hospital level but also at the community level discussing what a good service should look like and what it should provide.

The CCO acknowledged the importance of perinatal genetics. It was noted that funding has been provided for perinatal genetics services and that posts will be in place for this by the end of the year. The Committee welcomed that five post-natal hubs are in development.

The Chair thanked Ms. Lynch for her contribution and for sharing her story with the Committee.

The Chair and the Committee congratulated the CCO on receiving a fellowship from the Royal College of Physicians of Edinburgh.

The CCO Report was taken as read. The CCO reported to the Committee on several key areas as set out in his report. Discussions were held on the following aspects of the report.

In relation to the National Screening Service, the Committee was advised that the Coombe Hospital continue to pause HPV and cytology sample processing for CervicalCheck. The requested accreditation documentation was submitted to Irish National Accreditation Board (INAB) on 18th April and it is expected that INAB will complete an onsite visit before accreditation is restored. With sample processing at the Coombe Hospital currently paused, all CervicalCheck samples are being tested in Quest Diagnostics Inc. in the US.

The Committee was informed that the ‘CervicalCheck: Laboratory services’ tender is in process. The Chair informed the Committee that she is being kept updated on these matters via the CEO and the CCO.

The CCO provided an update on the Obstetric Event Support Team (OEST) programme for May and noted that feedback from the Just Culture Conference “Building a Just Culture in Healthcare: a HSE Dialogue” was very positive.

The Committee noted the recently published ‘National Cancer Registry Ireland (NCRI) Report: COVID-19 impact on cancer incidence in Ireland in 2021’ and the findings, which demonstrated that recovery in pickup of cancers had fallen off in 2020 but that concern remained over some subtypes including liver, pancreas, kidney and others.

In relation to the reconfiguration of Our Lady’s Hospital Navan (OLHN), the CCO informed the Committee that the oversight steering group continue to meet and that following their next meeting, there will be a meeting with the CEO to discuss a number of issues in respect of the current position of Navan Hospital and the date by which the final part of the reconfiguration process will be progressed.

The Committee was also provided with a high-level overview of the current statistics within OLHN regarding attendances. The CCO agreed to revert on Committee requests for data for the July Committee meeting.

The CCO provided an update regarding Letterkenny University Hospital’s (LUH) meeting with the SAOLTA Group, confirming that the CEO and CD SAOLTA outlined that they have a high degree of confidence with the information and feedback that they are receiving from the team. The CCO noted that recruitment remains challenging. The Committee was informed that the National Post- Menopausal Bleeding guidance has been published and training has taken place via webinars and lectures, focusing on endometrial cancer and raising awareness. The CCO advised that LUH have an ambulatory gynaecology service, with a key focus on the role of Advanced Nurse Practitioner (ANPs) and building the workforce.

The Committee was informed that following the publication of the National Strategy for accelerating Genetic and Genomic Medicine in Ireland in December 2022, a time-limited Taskforce was established to develop an implementation plan which was published in April 2023. An Implementation Steering Group (ISG) was established to lead and drive forward the implementation of the National Strategy as per the agreed implementation plan.

A CAMHS update was provided to the Committee, which was noted.

The CCO and NCDQPS outlined an engagement process that is ongoing between the Coroner’s Office and HSE’S National Clinical Director of Quality and Patient Safety with regards to shared learning from events and practices and policies. Some clarifications are required with regards to how to progress some matters and the Committee will be kept updated on this.

The Committee thanked the CCO for his attendance.

The Committee considered the Quality Profile from the April data cycle and requested that a detailed briefing regarding percentages of all attendees aged 75yrs and over at ED who are discharged or admitted within 9 hours be brought to the Committee’s July meeting. They also requested that a detailed briefing on Management of Chronic Disease be brought for further discussion.

Dr. Cathal O’Keeffe, Deputy Director and Head of Clinical Risk, State Claims Agency, provided a presentation on “Catastrophic claims relating to babies in maternity services”.

Dr. O’Keeffe presented data on, “Claims Analysis, Catastrophic claims relating to babies in maternity services - a five-year review”. He provided the definition of a catastrophic claim used by the State Claims Agency for the purposes of claims categorisation and outlined the inclusion criteria for the review. He presented a breakdown of the 80 claims received in terms of incidents which have occurred before or during labour (n=74) and those which occurred in the neonatal period (n=6).

Dr. O’Keeffe presented an analysis of the ‘Catastrophic claims concluded by year of incident and claim create date’ and the ‘Catastrophic claims concluded by paid damages, outstanding damages and value band’. He explained the six key issues that experts have found evidence of in relation to events occurring before or during labour and expanded on the seven key issues requiring attention. He provided an outline of the six claims that were made in relation to post-natal events. He also presented three key recommendations, arising out of the review, that had been agreed with the HSE/NWIHP.

The Committee welcomed the presentation made and discussed the recommendations made to implement mandatory multidisciplinary training in fetal monitoring and obstetric emergencies in all 19 maternity units. They discussed why training is not mandatory and it was noted that there is not a standardised training approach across all maternity units.

The Committee queried the level of funding required to implement training and commented that all mandatory training should be completed. Dr. O’Keeffe advised that multi-disciplinary training requires the whole team to be present and arranging cover can prove challenging. this can be challenging in busy hospital environments.

The Committee also discussed litigation costs and the factors driving these costs. Dr. O’Keeffe highlighted that in a recent international study, a reduction in litigation costs was associated with the introduction of Practical Obstetric Multi Professional Training (PROMPT) into maternity units.

Discussing the number of catastrophic incidents, the Committee queried international comparison and were advised that in terms of claims data, Ireland performs on average in line with England, per head of population.

The Committee sought further information regarding the number of claims received regarding fatal foetal abnormalities, and it was agreed that this data will be provided in advance of the next meeting.

In a discussion around birth plans, the Committee queried if any learnings had been made regarding people not taking the advice of their clinical team and how this could be shared. The Committee was advised that consent and documentation is shared in an aim to mitigate risks.

A question was raised as to whether the State Claims Agency engages with sites of incidents directly. The Committee was informed that they are moving towards this model, particularly for high value claims. Dr. O’Keeffe advised that in these cases, the feedback is provided to hospital’s senior management team, and it is requested that the learning be shared with the relevant staff.

NWIHP provided a paper prior to the meeting on the following areas: Patient Journey (covered under agenda item 4), Maternity Strategy Update, General NWIHP update, including abortion and the Annual Report 2022. These papers were taken as read and the Committee continued to discussions on the following aspects.

Obstetric Event Support Team (OEST)
As set out in the National Maternity Strategy (2016) and cognisant of HSE policies and procedures in the area of quality and risk, the OEST engages with hospitals for the purpose of providing support 6 and harvesting learning. An update regarding the implementation of recommendations, progress made and shared learnings across the system was welcomed by the Committee, however concerns were noted regarding challenges to progress implementation in one area. The Chair agreed to discuss this further with the CEO.

Termination of Pregnancy (TOP)
The Committee was informed that TOP has been challenging in 2023, with two reviews into the service and a commissioned report from the CCO. All recommendations will be put together into a single timebound implantation plan, which will be shared with the Committee.

Gynecological Services
The Committee was informed that work commenced within NWIHP in Q4 2022 to deliver on the Minister for Health’s commitment to commence provision of privately provided Advanced Human Reproduction (AHR) services in September 2023, with publicly provided services to commence coming on stream during 2024. NWIHP continue to engage with individual sites to roll out of ambulatory gynaecology services and it is anticipated that the capacity to see and treat women will continue to grow year on year. The Committee sought clarification regarding funding for fertility assisted human reproduction and were informed that currently only one cycle of IVF is publicly funded and privately provided but that this may involve several attempts arising from embryos stored from one cycle.

The Committee welcomed the update that as a key component of Sláintecare, NWIHP are continuing to expand dedicated Women’s Health Hubs in the Community.

The Committee discussed funding and resources challenges and it was agreed that the NWIHP Director would consider reverting to the Chair on any elements for NSP consideration. The Committee agreed to discuss NWIHP funding / resourcing through the lens of the NSP at its Committee meeting in September.

An update was provided with regards to the National Screening Service Strategy, Cervical Check Laboratory Services, Consultant Radiology Workforce, Expert Reference Group Interval Cancer Reports, Patient Safety Act 2023 and Corporate Risk Review 014: Sustainability of screening services.

The Committee noted and commended the inclusion of the ‘221 Group’ and other patient groups in the development of the review service in CervicalCheck, in addition to highlighting the importance of restoring public confidence in the Coombe Laboratory.

Ms. Murphy advised that the Legal Framework Group, one of the components of the Interval Cancer Steering Group, has considered the risks facing the NSS population screening programmes based on the current legal environment and is outlining recommendations as the minimum mitigation measures required. She advised that the final report is due for completion in Quarter 2, 2023 and will be provided to the Committee.

It was agreed that communication and public education also had dual roles to play in restoring public confidence. Ms. Murphy advised that they have some public representatives on their Quality Assurance Committee, that there is a culture of openness and that everything is discussed openly.

The Committee thanked Ms. Murphy for her presentation and looks forward to receiving the recommendations from the Legal Framework group in due course.

Corporate Risk Review 014
Sustainability of Screening Services was discussed and the five key actions proposed to reduce this risk were discussed.

The Committee queried whether all are satisfied with the name, mitigations etc. of the risk and it was noted that there was a desire to discuss the actions that might bring the risk down, at a later meeting.

Chair provided a high level overview of next Committee agenda which was agreed by members.