Attendees and apologies
- Fiona McQueen, Chief Nursing Officer (Chair), Scottish Government Chief Nursing Officer Directorate
- Keith Morris, Infection Control Doctor Advisor, Scottish Government Chief Nursing Officer Diredctorate
- Lesley Shepherd, HAI/AMR Professional Nurse Advisor, Scottish Government Chief Nursing Officer Directorate
- Angela Wallace, Nurse Director, NHS Forth Valley (and Interim Director of Infection Control, NHS GGC)
- Hazel Borland, Executive Director of Nursing, Midwifery and Allied Health Professions & Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran
- John Cuddihy, Parents Representative
- Craig White, Communications and Engagement Lead, Scottish Government
- Phil Raines, Scottish Government QEUH Business Support Unit (OB Secretariat)
- Carole Campariol-Scott, Scottish Government QEUH Business Support Unit (OB Secretariat)
- Marion Bain, Deputy Chief Medical Officer, Scottish Government
- Alan Morrison, Deputy Director, Health Infrastructure, Scottish Government
- Dr Andrew Murray, Medical Director, NHS Forth Valley
Items and actions
The Chair welcomed the group to what might well be the last meeting of the Oversight Board in the current form. The key agenda item for the meeting was the draft final report, and preparations for concluding this phase of the Oversight Board work with its publication.
Update on supporting work
The Chair noted that the draft final report has been supported by a number of key workstreams. Papers were circulated on each of the different workstreams below, and updates were provided for each one.
IPC and Governance
In Diane Murray’s absence, Phil Raines provided the update on the SBAR provided by the IPC and Governance Subgroup on the IPC Governance and Assurance Framework of NHS GGC. Members made the following points:
- the Framework document remains in draft, but it was noted that NHS GGC was intending to finalise after it could take account of the Oversight Board recommendations
- National work was needed to provide standard definitions and guidance around some of the key roles, such as Infection Control Doctors
- while the Framework provided a strong description of governance (with the caveats set out in the paper), how IPC governance worked in practice was the more critical issue
Water Safety Policy
Phil Raines presented the report by Ian Storrar of Health Facilities Scotland on the water safety policy description for the QEUH site of NHS GGC. Members of the Oversight Board noted the report and its recommendations.
The Chair thanked Ian Storrar for his assistance in this work.
Significant Adverse Event Reviews and Mortality/Morbidity Reviews
Craig White provided the update on the SBAR provided on SAER and Mortality/Morbidity Review policy within NHS GGC, which had been prepared with the assistance of SG policy colleagues in Healthcare Quality and Improvement. Members made the following points:
- the findings and recommendations of this work were endorsed
- the Case Note Review is also considering these issues, and their results should be fed into the Oversight Board Final Report
- it was important to understand what was known about any SAERs conducted on paediatric haemato-oncology patients within the period under review (including whether any were conducted for this patient community). Andrew Moore of Healthcare Improvement Scotland could advise on this
- Phil Raines to contact Andrew Moore regarding relevant SAERs
Draft Oversight Board Final Report
The Chair introduced the discussion on the draft final report. She noted the decision to split the findings and recommendations of the Oversight Board into two reports: the Interim Report had been published in December. The final report to be considered by the group covered the remaining key issues, particularly around IPC Governance. It was noted that it did not yet contain a recommendation around whether to de-escalate, on which members were asked to provide views.
Members of the Board made the following points:
- the final report’s findings and recommendations were endorsed. The Chair went through each of the ‘key questions’ in the Conclusions chapter to confirm the group’s agreement to the Oversight Board view on each question
- on IPC governance, it was recognised that it was difficult to fully conclude whether the key difficulties lay with what information/advice was being presented to the full Board from other parts of the IPC governance hierarchy and the extent to which it was fulfilling its challenge role in full. Nevertheless, the group agreed with the points made in the Governance chapter, especially around risk management
- the Case Note Review’s findings would need to be incorporated into the final report. It was noted that on the basis of Professor Stevens’ presentation to the Oversight Board before, those findings were broadly in line with what the Oversight Board was concluding
The Chair thanked the group for its views. On escalation, she would take further advice from John Connaghan and others in the Scottish Government on the approach being considered with respect to other Board escalations.
The next step entailed sharing the draft with NHS GGC for fact-checking and views. A revised version of the report would be circulated to the Oversight Board after that engagement for any final views before submission to the Cabinet Secretary.
The aim remained to publish the final report at the same times as the Case Note Review Overview Report. Mid-March remained the target date for both reports.
No other items were presented for discussion.
The Chair thanked the members of the Oversight Board and the various Subgroups for their huge contributions and patience with this work over the last year, not least in light of the challenges presented by the pandemic.
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