Statement by Minister for Health and Social Services re Independent Verita report on death of a patient with questions

STATEMENTS ON A MATTER OF OFFICIAL RESPONSIBILITY

6.  The Minister for Health and Social Services - statement concerning the Verita report The Deputy of Trinity (The Minister for Health and Social Services):

Yesterday I published the independent report by Verita into circumstances surrounding the tragic death of Elizabeth Rourke, as I promised I would in July 2009. Verita have conducted a thorough and detailed investigation and have built-up a clear picture of events. This is based on evidence taken from over 66 formal interviews and a review of all relevant notes and records. I would like to thank Verita for the work they have done. Verita have found that at the time of the incident which was in October 2006 - over 3 years ago - there was longstanding organisational weakness, particularly in the areas of governance. They concluded that these weaknesses may have contributed to Mrs. Rourke's death. Although Verita's terms of reference did not include a consideration of Mr. John Day's exclusion they did examine the criticisms made against him in relation to his actions on 17th October 2006. They did not agree with these criticisms. The report made a total of 29 recommendations, many of which concur with a finding of the hospital's own interim investigation. Of these a significant number have already been implemented or are currently being progressed, for example, we have already delivered improvements and processes associated with recruitment of locum medical staff. While progress has been made there is still much to do. It is essential that we succeed in creating a culture of openness in which staff feel they can raise concerns without fear of repercussions or public judgment. This ability to learn is a sign of a strong organisation. This is evidenced by the staff's response to the independent investigation. Staff at all levels, including doctors, nurses and managers, have been open and honest. In the words of Verita: "Everyone has behaved impeccably and the investigation process has been free from interference." While the report acknowledges that there are difficulties associated with delivering comprehensive healthcare on an Island isolated both geographically and organisationally, the report also points out that the hospital is a much-loved and valued institution. Every year we carry out around 11,000 operations and our patients rate our hospital more highly than the U.K. average in an independent survey. It is absolutely right that Islanders have confidence in the hospital and the service it provides. It is a safe environment but safe does not mean it is completely risk-free. As Verita have emphatically stated, even the world's leading institutions are not without incident. Surgery is, by its very nature, a risky activity. It is now time to move forward and meet the challenges ahead. This will not be easy. There are no quick fixes but I know that the dedication, skill and commitment of all my staff will be equal to this task. Since the beginning of 2010 Professor Aidan Hall igan, former Deputy Chief Medical Officer at the Department of Health and the Director of Education at University College Hospital, has been working with my staff to consider patient safety. As a Minister I am committed to taking the department forward and have asked Verita to return to Jersey in 6 months' time to report on our progress. Finally, I have never forgotten that at the heart of this incident is the loss of a much-loved wife, mother, friend and colleague. I would like to offer my sincere condolences to her family and friends, and acknowledge the dignity and courage that they have shown throughout.

1. Deputy T.M. Pitman:

I am certainly not a Member who has wanted to make such a tragedy a political football, nevertheless we have heard so many denials about a culture of cover-up existing and other failings, will the Minister now confirm that in due course - and I accept it is difficult what she can say - will someone finally be held accountable and face disciplinary action?

The Deputy of Trinity :

There are 29 recommendations and, as I have said, I am committed to working with ... some of those recommendations are already in place or in process of being placed. A disciplinary for whatever is ... we need to move on from that. We need to learn by what has happened and take that step and take it from there.

Deputy T.M. Pitman:

I do not feel the Minister has really answered the question. Will someone be held accountable? It is just a yes or no surely.

The Deputy of Trinity :

If the evidence had said that then it would have been so but disciplinary is not a way forward. We all must learn from it.

2. Senator S.C. Ferguson:

Given that this report exonerates Mr. Day, what disciplinary action will be taken against the other remaining members of the senior management team who were party to the totally unnecessary suspension?

The Deputy of Trinity :

It is very difficult to comment on that process because there is another investigation being done now by the States Employment Board which looks at the process of that exclusion back in 2006 and it would not be appropriate for me to comment because the report is not out and I do not know anymore than that.

3. Senator S.C. Ferguson:

Will the report be made public because there is a degree of public interest here?

The Deputy of Trinity :

The report was commissioned by the States Employment Board and it is a question which should be put to the chair of the States Employment Board.

4. The Deputy of St. John :

Firstly, could I offer my condolences to Mr. Rourke and his family for the loss and the ongoing inquest that is now to follow. Moving on, others have been hurt by this and I am going to refer to Mr. John Day having been suspended for 3 years. Will the Minister please confirm that his position has now been resolved and that he will be reinstated or otherwise without delay?

The Deputy of Trinity :

I can confirm that the acting Chief Executive Officer and Mr. Day have met this morning. Other than that, because it is employee/employer confidentiality, it is very difficult at this time to say any more.

5. Deputy P.V.F. Le Claire:

Having been chastised on a number of occasions for speaking out about a culture of fear and the culture within the hospital itself having been described by myself and surgeons that have spoken to me as one of repressive, does the Minister have plans to make sure that there is not necessarily disciplinary action but accountability for these issues and, at the same time, give us her opinion as to why she believes this report has done the job, given that Verita, who put together the report, were unable, despite several requests, to interview the doctor who performed the operation? In the words of Verita, it would have been far better if they had been able to speak to her. Does she not now concede that a Committee of Inquiry in this regard would have delivered that very important piece of work?

The Deputy of Trinity :

The current of openness and accountability is very important in any organisation and, as I said, it shows sign of a strength organisation. People must be able to speak out without fear of any repercussions but also, not be frightened to speak out because it is only by doing that, that the issues and problems are looked at and that anything that does come out of it is only for the better to make patient safety at the heart of all the care that we give at the hospital. Regarding why the Verita team were unable to meet with Dr. Moyano, that is something that was asked of the Verita team yesterday. All I can say, is they did try but she is, I understand, still ongoing investigations with the G.M.C. (General Medical Council) which will happen later on this year.

6. Deputy P.V.F. Le Claire:

I appreciate the Minister for Health and Social Services is in a difficult position and I do thank her for her answer but could I, with the most gentle way, press her to concede that a Committee of Inquiry would have compelled that lady to attend?

The Deputy of Trinity :

At the time it was well debated here and I am still of the same view. We have had a police investigation, we have had a Royal Court case, and a 9-month detailed investigation by Verita and there are still some questions to ask. That is when the G.M.C. will come into its own. I know the G.M.C. have already got a copy and it is for them to take that next step, which is, I agree, a very important step.

7. The Deputy of St. Martin :

I draw Members' attention to the answer given to written question number 13 - unlucky for some - that tells how much money this has really cost apart from the human suffering, but also the cost to the taxpayer, £137,000 just for legal fees alone without the £500,000 to Verita, et cetera. Can I draw the Minister's attention to paragraph 5, it says: "While progress has been made there is still much to do. It is essential that we succeed in creating a culture of openness in which the staff feel they can raise concerns without repercussions of public judgment." Can the Minister advise Members how this is going to be achieved if some of the key players are still in that position, could she elaborate please? I mean to say the key players of the senior management who have been severely criticised for their actions.

[14:30]

The Deputy of Trinity :

There are a great number of issues that they do raise in this report and it is not only within the management team, it is with organisational and different levels. As you know they do come under 8 separate headings. It is very easy to put blame but that does not, at the end of the day, achieve anything. What it achieves is the most important thing, is that we look at the recommendations and work on them to make sure that the hospital is a safe place. There are recommendations and I have, with Verita and with the departments, set a very tight timetable that they should come back in 6 months' time to see who will action, and how far we have progressed for those recommendations because that is vital.

8. The Deputy of St. Martin :

Could I just ask again when the lessons that were learnt that maybe the Minister will learn from the lessons or the failures with the Kathy Bull Report where the key players again who were criticised were then asked to put it back into the right situation. Can we ensure we do not have a repetition of that fiasco?

The Deputy of Trinity :

I hope not. I would like to think the hospital is already moving forward. I am in the process of appointing at the end of the month the new Chief Executive Officer and from that, as in one of the recommendations, that we should have a Hospital Director to divide at operational and strategic levels, which is quite right, and that should have been done a long time ago. So from the appointment of the Chief Executive Officer at the end of the month, whoever he or she is, will be involved in the appointment of a Hospital Director, a Medical Director and also a Director of Social Services. So, you can see that things are in place. I am determined and I have said I am committed to make sure that this hospital ...

The Bailiff :

I think, Minister, you have said that before and I want as many Members as possible to be able to ask questions.

Deputy M. Tadier :

My question has already been asked by the previous speaker.

9. Deputy R.G. Le Hérissier:

Building on Deputy Hill's question, does the Minister not acknowledge that in the Verita report there was much talk about cosiness, about conflicts of interest in small places, about the fact that people's loyalties get strained in the situation? Does she not acknowledge that there is little purpose in having paper adherence to 26-29 recommendations? What we need is radical organisational change [Approbation] and that has not been reflected in the answer she is giving. Nobody is seeking blame but we are seeking radical change to introduce real checks and balances that have hitherto not existed.

The Deputy of Trinity :

I would like to think that is what I am committed to doing as well, and I think the top management will be changing but this is, I think, where one of the strengths is going to be from, as I mentioned. Professor Aidan Hall igan, who is already beginning some work: that will be one of his roles when he does come over.

10. Deputy M.R. Higgins:

Given the management failures and blame culture that permeated in the hospital, can the Minister advise the Assembly whether the former chief officer who allegedly resigned for personal reasons was given any enhanced payment when he left the States employment other than the normal notice period payments?

The Deputy of Trinity :

That is very much a contractual agreement and something I cannot comment on.

Deputy M.R. Higgins:

I am not asking for the amount, I am just asking whether he received any payment in excess of the normal notice period.

The Deputy of Trinity :

My answer is still the same. It is a contractual agreement between that person and the States Employment Board.

11. Connétable D.W. Mezbourian of St. Lawrence :

It is really trying to get clarity from the Minister on previous questions, and she has mentioned a few times moving forward and looking at the recommendations, but what exactly is she going to do to change the culture at the hospital? What will she be implementing, forgetting what the recommendations are from Verita; what does she want and what will she do?

The Deputy of Trinity :

What do I want? I want a hospital that I think the Island is proud of. As a patient, it is an area across Health and Social Services that puts patients at the heart of everything that we do and that it is a safe environment. What will I do? The first thing I will do is these recommendations are important. I know they may seem in bits and whatever, but they do get down to the nitty- gritty of hospital life and it is important that in the next couple of weeks that these recommendations and these... they will be itemised on who is responsible for doing what and what action and what timescale. Some of these recommendations have been put in place; regarding locums has been much tighter and it is still progressing to make sure that the hospital continues to be a safe place.