HSE Safety and Quality Committee meeting minutes 17 November 2021

Committee Members Present

Prof. Deirdre Madden (Chair), Dr. Yvonne Traynor, Ms. Anne Carrigy, Ms. Margaret Murphy, Dr. Cathal O’Keeffe.

Apologies

Prof Fergus O’Kelly, Dr. Chris Luke, Ms. Jacqui Browne

HSE Executive Attendance

Dr. Colm Henry (CCO), Mr. Dean Sullivan (CSO), Mr. Patrick Lynch (ND GR), Dr. Orla Healy (NDQPS), Ms. Yvonne O’Neill (ND COM OPS) Ms. Niamh Drew (Secretary), Mr. Pat Galvin.

Joined the meeting

Mr. Killian McGrane, Dr. Peter McKenna, Ms. Angela Dunne, (Item 9), Mr. James McGrath (Item 2), Mr. Bernie McNally (Item 3)

The following items were discussed and noted.

Minutes of the Meeting on 20th October were approved.

No matters arose and no conflict of interest were declared.

The Committee briefly discussed the Letter of Determination received from the Minister for Health Office and the priorities for the S&Q Committee within. It was felt that it is important that the Committee are aware of the ministerial priorities, with waiting list and waiting times being one of the top priorities. Other priorities mentioned, relevant to this Committee, included Women’s Health, Social Inclusion, National Service Plan and Mental Health all of which will be reflected in the annual Committee workplan. The Committee also noted that providing reassurance of the public was important and it was agreed that during 2022 the ND of Communications would be invited to attend a meeting to discuss the Communications Strategy.

Dr. Colm Henry provided an update of the CCO report to the Committee. The CCO report included high level updates on the vaccination program, vaccine booster doses, antigen testing programme, hospital acquired Covid-19 resulting in admission to ICU, Breast check report update, Letterkenny University Hospital, South Kerry CAMHS update and a learning notice on maternal mortality.

Vaccination Programme

The Committee was informed that over 7.6 million vaccines were administered to the 7th November, including ca. 53,000 third doses to immunocompromised persons and over ca. 197,000 booster doses which began on the 30th of September.

It was noted that the roll out of vaccines has continued through the pharmacies with ca.331,000 administered as of 7th November.

The CCO informed the Committee that the Covid-19 booster vaccination programme for residents aged 65 and over in Long Term Residential Care facilities commenced October 4th, 2021. This group was substantially completed w/c 25th October; however, some facilities may need to be revisited due to eligibility timeline. The programme was extended to residents aged 60+ in Long Term Residential Care Facilities and commenced last week (w/o 1st November). In total ca.26,000 booster doses have been administered to the LTCF residents. In response to NIAC guidance given on Monday November 1st, Vaccination centres commenced vaccinating HCWs over the weekend of the 6th and 7th of November.

Antigen Testing Programmes

The antigen programmes in Early childcare, Further and Higher Education and Residential Care Facilities (RCFs) for Older Persons are ongoing and results are reported via the online system. Most sites have completed 4 weeks of testing, but due to staggered start dates there are a few facilities who are still to finish the programme. An evaluation of the Education sector has been completed and evaluation of the RCF programme is underway. Any further roll-out will be based on Public Health recommendations and advice from the Rapid Antigen Test Taskforce.

Antigen testing of close contacts who are fully vaccinated and have no symptoms commenced on 28th October. A box of antigen tests is delivered by post to the individual’s home and a range of information and resources has been made available to support the user in completing the course of antigen tests.

A total of 25,718 close contacts have been referred for antigen tests since the programme commenced last weekend, with an average of 3,000 referrals per day over the last 7 days.

Antigen testing results

The online system for reporting antigen self-test results is available for any antigen user to report their results, whether part of an HSE programme or other members of the general public. Antigen test results, symptomatic status and vaccination status are self-reported and not subject to validation. To date, 41,238 results have been entered with an average of 1,694 per day for the last 7 days. 82% of positive antigen results are confirmed cases on PCR testing, an average of 1,102 cases per day.

Antigen Test Kit Distribution

A pathway for distribution of antigen tests via pharmacies is at the advanced stages of development. This model could support the wider roll out of antigen testing to identified cohorts if required, whether as a public health measure, screening programme or as a surge capacity measure to mitigate PCR testing demand.

Request for data specific to hospital acquired COVID-19 resulting in admission to Intensive Care Units (ICU)

In the ICU dataset, 154 cases were reported to be “hospital acquired” out of a total of 1,883 ICU admissions, 8.2% (data from 1st March 2020 to 30th September 2021).

Verbal update on Breast Check Expert Reference Group Report on Interval Cancers

The committee were given an update on this item and were advised of a timeline of 6 weeks to request data sheets and a notice is to be added to HSE Website advising of these details. Concern was raised about the timeline being very close to Christmas. After that date, records would be destroyed in line with the HSE retention and destruction policy and GDPR legislation.

Update on Letterkenny University Hospital (LUH)

The Saolta Group has been progressing implementation of the Price Report recommendations through an Implementation Group convened in September 2020 and significant progress has been made. This Group will remain in place and will continue to oversee implementation of the recommendations and service improvements to ensure all are fully implemented and to assure sustainability of the improvements. An action plan following the withdrawal of the special measures team remains live and continues to drive activity on site to implement recommendations. Both LUH and the Saolta Group will continue the ongoing work to address all areas identified for improvement. A national Key Performance Indicator for the investigation is being developed and will be added to the Quality Profile presented at the Safety & Quality Committee.

Community Operations update on South Kerry CAMHS

The Committee was given details of a lookback report on South Kerry CAMHS. They were advised that the HSE has reviewed the treatment received by children and young people who attended the South Kerry Child and Adolescent Mental Health Services (CAMHS) between July 2016 and April 2021. Of 2,000 records screened, 1495 were identified as falling within the time periods and requiring further review. A further 43 cases under the governance of the North Kerry CAMHS Team also merit review. The team has reviewed the files of everyone who received care from South Kerry CAMHS between July 2016 and April 2021 (more than 1,500 files) and the HSE have written to all of the young people or where appropriate, their families, to let them know what the review found in their care.

At this point, in excess of 200 of a total of 240 families and children, have been met by a combination of senior Clinicians and managers through the Open Disclosure process. Meetings for the remaining 40 or so are scheduled to take place over the coming 2 weeks. The original timeframe was extended to facilitate some families where the original schedule was not suitable and also to ensure the availability of Senior Clinicians to undertake the individual meetings. Minutes of the individual Open Disclosure meetings that have taken place already have been shared with the families for their information and to also to reiterate the apology from the HSE.

The final report from the review team is expected at the end of November and the report’s findings and recommendations will be published thereafter. The HSE is undertaking the investigation in line with formal Incident Reporting processes and Review of Incidences Framework. The HSE is liaising appropriately with other bodies, including Tusla in the context of its obligations to the children and in light of its obligations under the Children First policy.

The HSE remain mindful of the need to maintain the principle of systemic review and open disclosure.

The HSE’s priority is to communicate directly with the young people and families; and to ensure that the review process ultimately provides them with a clear overview of what happened.

The Committee was provided with an update regarding the publication of the NIRP report. Following extensive discussion of the important issues raised by the Report, the Committee formed the view that publication of the ‘National Independent Review Panel – Brandon Report for Publication’, is the appropriate approach to take in order to strike a balance between commitment to transparency and ensuring the integrity and independence of the NIRP process. In this regard, the ‘National Independent Review Panel – Brandon Report for Publication’ contains all the salient facts but does not identify the residents or their families, the care home, the locality or any of the staff.

The ND of Governance and Risk gave the Committee an update on the Q3 Risk Review.

CRR Update – Q3 2021 review was completed in September. The Q3 report was considered by the ARC at its November meeting. It will be presented to the Board at its next meeting as part of the annual approval of the CRR.

A new Pandemic risk assessment, [Risk of another Pandemic] remains outstanding and the ARC have requested that this work be completed as soon as possible. The Covid-19 related risks on the CRR are more dynamic and the risk profile has changed since the Q3 review was undertaken with the recent surge in infections.

An update on the 12 ‘critical path’ recommendations from the Moody Report was provided.

It was noted that Digital Government Oversight Group has given its approval to the new Risk Information System.

The draft Risk Appetite Statement [RAS] will be presented to the Board for approval following which It will be tabled for a meeting of the S&Q Committee. The operation of the RAS will be reviewed after 12 months and this review process will involve the Board Committees.

The Chief Strategy Officer gave a brief update on Risk 18 Policy& Legislation Development & Implementation. With the new Oversight Agreement in place between the HSE and DOH, this risk has reduced. It is anticipated that as a result this risk is likely to be removed from the Corporate Risk Register at the next Review.

Professor Orla Healy presented the Quality Profile which was viewed and discussed. Some of the most noticeable metrics was staff absence, which is quite high at the moment and is Covid related. Committee discussed the impact of unvaccinated staff causing on the system and it was greed that further information and data on this would be provided at the next meeting. the Committee also discussed Delayed Transfers of Care and Child Assessment of Needs and it was agreed that improvement plans for these two areas would be brought to the next meeting.

A report demonstrating the impact of the HSE cyber-attack on incident reporting to NIMS, prepared for the HSE by the SCA, was presented by the National Director for Quality and Patient Safety. The reported demonstrated a significant drop-off in reporting of incidents to NIMS in the wake of the cyber-attack, at which time access to NIMS by health and social care was suspended. The Committee noted that incidents occurring from 1st July to 23rd August, all locations have a drop off in 2021 compared to the two previous years and Hospital Groups were down 58.2%, CHOs were down 62.5% in 2021 from 2020, and other locations down 29.4%. The largest drop for a Hospital Group is Group 4 with over a 76.3% drop from 2020 to 2021, with 6 hospitals showing a decrease of over 60%. CHO 3 shows a drop of 80.6%, which is the largest drop for any location.

The Committee were updated with a presentation about St Vincent’s Older Person’s Community Nursing Unit in Mount Mellick and how they coped with the running of the centre and caring for the residents during the difficult time when Covid-19 started. The Committee welcomed the presentation and thanked Ms Phelan for her true and honest presentation of dealing with Covid-19 in a real-life situation.

The Committee were presented with a high-level overview by the National Director of Community Operations. It was explained that the high level of virus circulating in the community continues to present risks and the HSE monitor a large number of COVID-19 outbreaks in RCFs. At 09/11/21, Public Health reported 147 open outbreaks across these facilities. Within Older Persons services, there are 54 Nursing Homes (Private) and 15 CNUs/Community Hospitals (Public) in outbreak. Of the remaining 78 outbreaks, 67 relate to Disability, Mental Health and Addiction services, while 11 outbreaks occurred across TUSLA, Religious Orders, Prisons and other facilities not within the HSE. While a number of facilities are experiencing significant outbreaks requiring extensive supports from the HSE, Public Health data and infection rates indicate outbreaks overall are more effectively contained compared to earlier in the pandemic. In outbreaks where the number of staff absent on COVID-19 related or other sick leave are posing potential risks, these are mitigated through active support to providers around staff contingency planning, and for HSE operated RCFs by ongoing review of managers with a view to bring in agency staff or staff redeployments to maintain safe staffing levels.

The HSE keep the outbreak situation under close review, and in collaboration with the Regulators, as per agreed communication protocols, ensure risks are identified and appropriately escalated.

The Committee were provided with an overview presentation from the NWIHP representatives on three key elements of their programme – Ministerial Priorities for Women’s Health, Quality & Safety, and Gynaecology.

Mr McGrane advised that NWHIP do not have direct involvement in 2 areas, Contraception and Gynaecology but they are on track with all the other initiatives, with 87% of the priorities ongoing including the Irish Maternity Indicator System and the Maternity and Infant Scheme. The Committee were informed that 11 sites were funded for Ambulatory Gynaecology in 2021. It is hoped that the smaller units will see 1000 patients and with bigger units seeing twice that amount, as well as working towards real time waiting lists. Committee members asked about Assisted Human Reproduction (AHR), to which they were advised that the Government has not committed to that, as of yet. The Assessment aspect of AHR will be available but the treatment is not yet available. It was explained that it would need 300 cycles a year for it to work from a costing perspective.

Ministerial Priorities for Women’s Health

The Minister has made clear that women’s health is a key priority area for him, and this is reflected in the budget allocation in 2022 and with women’s health listed as number two in the Ministerial priorities in the Letter of Determination. Central to that priority is the implementation of the National Maternity Strategy (NMS). NWIHP’s Annual Report 2020 was published on the HSE website over the summer and set out a number of key achievements during the year.

Quality and Safety

Quality and safety remain a primary focus for the programme. During 2021 a Quality and Safety manager was appointed, who works closely with the Clinical Director in driving improvements in quality and safety.

Gynaecology

NWIHP’s focus on gynaecology resulted from the challenges presented by the cervical check audit in 2018, and the growing waiting lists. NWIHP developed a Model of Care (MOC) for ambulatory gynaecology and using funding from other sources established three sites in 2020 – CUMH, Rotunda and UHG. At the end of 2021 there are 14 hospitals funded for ambulatory gynaecology. The 2022 budget allocation means that by the end of 2022 20 hospitals will be funded for ambulatory gynaecology (19 maternity hospital and Tallaght University Hospital).

The Committee Chair thanked the members of NWIHP for attending and giving their presentation.

Next Meeting is 14th December 2021.

Meeting Concluded at 16:00 pm.