The information below sets out the process by which all incidents and mortalities are to be discussed and reviewed within the North West, North Wales and the Isle of Man Congenital Heart Disease Network. It describes how learning from investigations is shared. The process also provides an opportunity to learn from complaints and to celebrate and share best practice where this has occurred.
Network Responsibility
In line with the Congenital Heart Disease Standards & Specifications, NHS England, May 2016 (Standard F3) the Network will operate within a governance framework that will include:
- Clinical Governance meetings to be held every 6 months
- Oversight of all incidents relating to paediatric cardiology and adult congenital heart disease that have occurred throughout the Network
- Discuss individual incidents that had the potential to or have actually caused harm where there is a Network wide implication or lessons to be learnt
- Review all mortalities where a diagnosis of paediatric cardiac disease or adult congenital heart disease has been a cause of death
- Provide a summary of all lessons learnt and ensure these are shared
- Support providers to implement any actions that are recommended
- Resultant changes in pathways to be agreed at the CHD Network Board and shared
- Inform clinicians and providers of any changes in practice that have been identified as being necessary
Providers Responsibility
These requirements do not replace an individual provider’s responsibility to report and act upon incidents and mortality reviews within their own institution. The reporting to the Network should be seen as additional to and not instead of local reporting and actions.
Each hospital is required to follow its own internal incident reporting process and mortality reviews locally. All incidents need to have been investigated and any lessons learnt identified prior to reporting to the Network. All deaths similarly need to have been discussed locally and if a coroner’s inquest is required this must have concluded with an outcome prior to being submitted to the Network. Where it is deemed clinically appropriate to discuss cases more urgently and prior to any local investigations being concluded – this will need to be discussed and agreed with the Network Senior Leadership Team.
Each provider is requested to nominate a named individual to be responsible for submitting clinical incidents to the Network every 6 months. It will be their responsibility to submit the online clinical governance report. They will also be asked to provide the name and contact number of the person identified to attend the clinical governance meeting to provide a summary of the high level incidents.
Reporting Process
The Network will inform all providers of the reporting dates every six months. These dates will be provided at least 2-3 months in advance to allow clinical activity to be accommodated. Providers will be given a month to gather the information for the online report with notification of what date the reporting window will close. After this date no further submissions will be accepted.
The Clinical Governance Reporting Form
Providers are requested to complete one form every 6 months. No patient identifiable information is to be submitted to the Network. The report will be submitted securely on line via Microsoft Forms via this link: https://forms.office.com/e/Gsu3i1ktMk
The Clinical Governance Report includes:
– An overall number of incidents in each Trust
– Categories of harm to be identified as per NHS England patient safety recommendations
– Lesson learnt locally and any actions plans agreed
– Report any change of practice that may be useful to share across the Network
– All complaints reported via PALS
– Share best practice
– Celebrate excellence
– Update regarding relevant audits or research
Categories of Harm:
Current Clinical Governance Dates
Incident Reporting Process
Incidents that require discussion at the clinical governance meeting should be reported to the Network by completing an Incident Reporting Form. This should include all category harm C-D incidents. This may on occasion include low level harm incidents if it is felt that benefit would be derived from lessons learnt and shared across the Network.
Click here to access our Clinical Governance documents.
Mortality Reporting Process
All deaths where a paediatric cardiac condition or adult congenital heart disease has been identified as a cause of death are reportable to the Network using the standardised Mortality Reporting Form.
Click here to access our Clinical Governance documents.
Confidential Emails
All patient identifiable information is to be removed from incident and mortality reporting forms prior to sending to the Network via email. It is the responsibility of the person sending the email to ensure that data protection and information governance considerations are complied with. Information sent between email addresses that are both registered as being compliant with DCB1596 standards do not need to be encrypted. This can be checked here: https://digital.nhs.uk/services/nhsmail/the-secure-email-standard#list-of-accredited-organisations. Otherwise all emails are to be encrypted.
The Network secure email address: northwestchdnetwork@alderhey.nhs.uk is compliant with DCB1596 standards.
Prior to the Clinical Governance Meeting
The Clinical Directors of the Network alongside the Lead nurse will review all submissions and will be responsible for deciding which incidents and mortalities will be discussed at the meeting. Additional information may be required and requested prior to the meeting. The Lead Nurse will contact everyone who is due to present to confirm attendance. An agenda will be circulated 2 weeks prior to the clinical governance meeting.
During the Clinical Governance Meeting
The Network Lead Nurse will chair the clinical governance meetings and will be supported by the Governance Leads for the Network. Meetings will be held remotely via Microsoft Teams.
Presenters will be asked to provide a high level summary only of the incidents or mortalities with a priority on the local learning points and considerations for the Network to discuss.
– All actions will be identified and tracked
– Person/Trust/Network responsible and time frames to review/complete
– Summary of lessons learnt
– Key themes from each meeting will be identified
– Any good catches
– Examples of good practice
– Summary of audits/research
Following the Clinical Governance Meeting
A summary of the meeting will be circulated to everyone within the Network in a one page format. In addition the Network will :
– Ensure actions that require operational input are discussed at regular meetings between the Network and provider
– A summary of the outcomes will be reported to the Network CHD Board
– Provide a summary for commissioners in both England and Wales on request