Independent Oversight and Assurance Group on Tayside's Mental Health Services

Appendix 5: Saer Review - Subject Matter Expert Remit and Report

Review of completed SAERs in NHS Tayside for the Independent Oversight and Assurance Group on Tayside's Mental Health Services

What

To review SAERs completed by NHS Tayside under their new policy. There are 5 in total and it will be at the discretion of the Subject Matter Experts whether it is appropriate and necessary to review all 5 or whether a sample is sufficient.

Why

The Oversight Group requires the help of external Subject Matter Experts to assess the quality of completed SAERs by NHS Tayside, in terms of gleaning the most meaningful conclusions from the information gathered as part of the SAER process, and ensuring that both those conclusions, and then actions, follow logically from the findings. This includes assessing the effective application of the NHS Tayside policy for responding to significant adverse events; the effective engagement of families and carers; as well as the sufficient development and implementation of a learning culture.

How

The process will involve reviewing only the final reports from the completed SAERs, which the Oversight Group will request from colleagues in NHS Tayside. Patient information will be redacted to ensure there are no confidentiality concerns. The process will also involve consideration of the Adverse Event Policy written and used in NHS Tayside.

Who

The review will be conducted by:

Dr Adam Daly

Associate Medical Director (MH&LD, NHS Lanarkshire)

Consultant in Old Age Psychiatry

Mr Peter Lerpiniere

Associate Director of Nursing

NHS Borders

Timescales

This work requires completion by the end of September 2022 to allow the findings to be reflected in the Oversight Group's final report at the end of October.

August 2022

Review of completed SAERs in NHS Tayside for the Independent Oversight and Assurance Group on Tayside's Mental Health Services

Dr Adam Daly

Associate Medical Director (MH&LD, NHS Lanarkshire)

Consultant in Old Age Psychiatry

Peter Lerpiniere

Associate Director of Nursing (MH, LD & Older People)

NHS Borders

Background

Dr Daly and Mr Lerpiniere (referred to hereafter as the review panel) were identified as subject matter experts in both mental health and the process of conducting Significant Adverse Event Reviews (SAERs). The review panel were commissioned to conduct a review of completed SAERs by the Chair of the Independent Oversight and Assurance Group on Tayside's Mental Health Services. This piece of work thus forms only a part of a wider program of work and should be taken in context.

The remit of the review was set out as follows:

What

To review SAERs completed by NHS Tayside under their new policy. There are 5 in total and it will be at the discretion of the Subject Matter Experts whether it is appropriate and necessary to review all 5 or whether a sample is sufficient.

Why

The Oversight Group requires the help of external Subject Matter Experts to assess the quality of completed SAERs by NHS Tayside, in terms of gleaning the most meaningful conclusions from the information gathered as part of the SAER process, and ensuring that both those conclusions, and then actions, follow logically from the findings. This includes assessing the effective application of the NHS Tayside policy for responding to significant adverse events; the effective engagement of families and carers; as well as the sufficient development and implementation of a learning culture.

How

The process will involve reviewing only the final reports from the completed SAERs, which the Oversight Group will request from colleagues in NHS Tayside. Patient information will be redacted to ensure there are no confidentiality concerns. The process will also involve consideration of the Adverse Event Policy written and used in NHS Tayside.

Process

The following documents were obtained, scrutinised and cross referenced by the review panel:

• 5 completed NHS Tayside SAERs
• Action plans for the above SAERs
• Adverse Event Management (AEM) Policy (January 2022), NHS Tayside
• NHS Tayside Mental Health & Learning Disability (MHLD) Service Significant Adverse Event Review (SAER) Oversight Group Terms of Reference (July 2022)
• Protocol for use following Unexpected Death in Mental Health and Substance Misuse Services
• Mental Health Services –Clinical Governance Arrangements (PowerPoint, NHS Tayside)
• Learning from adverse events through reporting and review: A national framework for Scotland (December 2019), Healthcare Improvement Scotland

In addition, the review panel were able to interview:

• The Associate Medical Director Patient Safety, Clinical Governance and Risk Management in NHS Tayside
• An independent reviewer who has undergone the new training process and has conducted SAERs for NHS Tayside

Findings

The review panel noted that the SAERs in question had been completed prior to the introduction of the new Adverse Event Management (AEM) policy. This presented several challenges – although it is within the remit of the exercise the review panel acknowledge that it would be unreasonable to expect reviews to be measured against a process which had not yet been written. However, the HIS document "Learning from adverse events through reporting and review" is a key document for reviews throughout Scotland and predates the reviews in question. The AEM policy references this document among multiple other relevant documents – and is clearly referencing the standards in its approach. Thus the HIS document is a suitable and useful comparator to use and we have compared against this. We also used the content of our interviews to inform this section of the report.

• Policy and Procedure

The review team examined a suite of documents relating to adverse event management. NHS Tayside's Adverse Event Management Policy is a thorough piece of work and sets out in detail a consistency of approach which will even out some of the inconsistencies cited below. In addition the training of reviewers will aid in ensuring further consistency of approach and an improved quality of review and report. The reviewer we spoke to felt well trained for their role prior to starting, and well supported during the review process while recognising that an improvement journey is never complete.

• Overall impressions of the reviews

The review panel have been struck by the variability in the reviews presented. All 5 reviews are distinct in terms of their style, tone, length and layout. It is likely that this is due to the lack of an overall template and training, both of which have been remedied under the new policy and associated processes. Given the aspiration is toward an improved Patient Safety focus, and while one review may be considered more explanatory and less analytical of practice than the others, we consider this was maintained throughout. There is a clear intention to identify good-practice to share and areas to learn from.

Four of the five reviews were of a good level and largely what we would expect of an SAER. The fifth had many components we would expect but read more in line with a complaint response, heavily reliant on the families queries rather than taking direction from both the healthcare organisation and the family.

• Review processes

The review panel found that there was evidence of a team being created for each review, comprising of an external team lead (this is someone not associated with the team being reviewed, but employed by NHS Tayside for the purpose of the review), and a local service manager. In some instances due to the redaction used it was challenging to ascertain the exact nature of the staff involved in the review team. Subject matter experts were available on request, and for peer review of final reports. The review panel felt that the reviewer could be in an isolated position, but this was not mentioned in or inferred from any of the review documents.

In most of the SAERs a Terms of Reference and/or Scope is quoted to allow the reviewer to be precise about their remit. There is evidence that reviewers were able to deviate from this where needed and had the freedom to pursue other avenues of inquiry as they arose.

Reviewers had access to notes, electronic resources and staff as needed.

In all reviews there was clear engagement with both family and staff. Questions from family were incorporated into reviews, although in some instances engagement with the family was not successful and we acknowledge this not an uncommon issue for review teams.

There is evidence that views from those working in services have been incorporated. The way this is written is mostly in fashion which fits the Just Culture that is being aspired to. This supports the safety culture of an organisation.

In several reviews there is evidence of methodology using tools supported by HIS.

• Review Findings

We were specifically interested in seeing if findings followed logically from the review contents, and in most cases this was evident and the explanation was clear. There were no extraneous additional findings. In some reviews these were separated into good practice and areas for improvement. In most cases a conclusion was reached on the extent to which the findings contributed toward the outcome.

• Recommendations

The review panel felt that predominantly recommendations followed logically from findings. In the reviews examined the review panel noted that actions were not formulated by the SAER team. Instead a recommendation was created which was later reformulated into an action by service management staff. The review panel were able to review such action lists and implementation plans and confirm this. These actions were Specific, Measurable, Achievable, Realistic and Time Bound (SMART) as per best practice in this area.

• Evidence of Learning Culture and dissemination

In most reviews there appears evidence of both intent and plan to feedback to staff and often the wider organisation regarding the findings and conclusions. As with other aspects this was not consistent across every case.

• Alignment with HIS Adverse Events framework

The review panel were keen to see if the reviews aligned with the HIS Framework, including the overarching principles of

• Emphasis on learning and promoting good practice
• System approach
• Openness about failures
• Just culture
• Positive safety culture
• Personal, professional and organisational accountability
• Teamwork

The review panel felt that in most of the cases examined these features were evident either explicitly or implicitly. Under the new review structures this will be more explicit.

• Areas for improvement

The review panel did feel that the lack of consistency was the main area of weakness of the review process as it previously stood. Variability has a higher chance of leading to errors, and in this case some reviews did not mention significant issues, most notably duty of candour. The review panel notes and welcomes that variability will be significantly reduced under the new policy and process.

Due to redactions made as part of the release of the reviews to the review panel, it was not possible to comment on the completion time of the reviews.