Transcript Supervisory Investigation Workshop
Report Writing Workshop
BARBARA KUYPERS & TONI MARTIN LSA WEST MIDLANDS 2012
Expected outcomes from the day
Exploration of any issues of concern for you and your team Principles of report writing Summing up your findings for the report Making recommendations to the LSA
Future Legislation
Changes to Midwives Rules Changes to the NMC The impact on SOMs and Midwives
What the NMC expects
Professionals entering and remaining on the register to be of good health and character Honest and trustworthy Assessment based on conduct and behaviour of the registrant Your character must be sufficiently good for you to be capable of safe and effective midwifery practice without supervision The SOM to be able to handle conflict and achieve consensus ensuring no party feels disadvantaged
Principles of report Writing
Guide to report writing www.npsa.nhs.uk
Provides good overview and worth examining Purpose of the report To convey all necessary information about the incident, the investigation process and the outcome of the investigation To present a culmination of all the work you have undertaken Provide a formal record of the process and is a means of sharing learning
Principles of report Writing
The report should explain What happened, a chronology of events and your investigation Who it happened to When Where How (what went wrong) Why (contributory factors Think of your audience – the midwife, the LSA, the family, the NMC
Writing the investigation report
Section 1 - should have sufficient detail to understand what prompted the investigation. The reader should be able to understand why you decided to investigate. Use of decision tree?
This is a description of the incident and its consequences Avoid emotional, judgemental language Section 2 – brief employment and supervisory details of the midwife. Ensure dates are completed
Writing the investigation report
Section 3 – Chronology - ESSENTIAL to begin as soon as possible and keep up to date. Put as much information as possible in this section as it shows the methodology you followed; the reasons for delays; failure to meet the deadline This section should be continued to the end of the investigation including dates report sent to the LSA; final report submission; Details on when and how the midwife was informed of the findings; Date the summary report sent to the HOM and ideally date the developmental support/supervised practice programme started
Dates (2012) Event
process and events summary
Health professionals, family, Midwives and SoMs involved
Chronology
SOM Commentary Signpost to supporting documents April
Incident identified which occurred on April.
HOM Risk Manager Investigating SOM As documented in description.
Having identified the incident as consultant midwife - I informed (Head of Midwifery) and (Risk Manager).We met to discuss the case and we all agreed that a formal SOM investigation should take place. Until the investigation completed it was agreed that TM should not provide intrapartum care until investigation findings were ascertained.
She was advised to work on the PN ward & PN Ward manager informed ( April).
Meeting date to interview TM set for April. TM named SOM informed and happy to support.
Copy of incident form kept in SOM investigation file along with all letters inviting for interview/ around table meeting.
April
Debrief with shift leader and identified a managerial gap in competence framework Witness 1 Senior midwife Area manager Witness 1 – debrief 1 hour as shift leader for the case before SOM investigation instigated.
Identified that she had not formally achieved shift leader requirements re competency to shift lead the department. Manager notified to address and witness 1 advised not to shift lead till competency confirmed.
Email correspondence with Area manager and verbal discussion April
SOM investigation commenced Midwives involved in case seen by (SOM) All midwives involved asked to provide statements All midwives informed that a SOM investigation underway either verbally or email (one midwife on leave).
I met with TM for about 1 hour to explain the SOM investigation face to face and why. This was put in writing
Appendix 1 April April
LSAMO informed
Interview Midwife Inv SOM Named SOM Scribe
Using instigation of SOM investigation also copied to link SOM and HOM
Appendix 2 Interview notes prepared from case notes and statements including TM’s original statement dated h April Appendix 3 Kept on file Statement already submitted by TM but not seen by her named SOM. I recommended that her named SOM review with her which she brought to the meeting and was reviewed by all of us. From the case notes and what was established at the meeting it was agreed that all points had been covered and there was nothing new highlighted (dated April).
Letter sent following Interview to Interview notes finalised Discussion with LSAMO Inv SOM Copy named SOM
TM Inv SOM Named SOM Scribe Inv SOM LSAMO
Round Table meeting arranged Round Table Meeting took place
TM Witness 1 Witness 2 Inv SOM Named SOM Scribe
Appendix 4 Appendix 5
Having read statements and spoken in detail to TM I discussed that I would like to support TM back into intrapartum care as I thought that lessons had been learned. My thoughts were to provide some supernumerary support 37.5 hours with a developmental support programme utilising reflective practice. LSAMO supported this decision
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Meeting took place Preparatory notes made for the meeting which have been incorporated into the round table final notes that have been agreed by all in attendance.
Productive meeting which lasted about 1.5 hours.
Apparent that lessons have been learned by all It was agreed with SOMs in attendance and myself that the error appeared to be in Fiona’s communication of events All demonstrated in the meeting how they would manage the situation differently in future. Witness 1 and 2 described how they would have done things differently had TM informed them of the issues she was dealing with.
I was happy as a SOM having had the opportunity to discuss in detail at the meeting that nothing further was required for Witness 1 or 2
Appendix 6 Letter to TM RE: Developmental support
TM
Outcome of the investigation
TM Named SOM SOM investigator
Draft SOM report Inv SOM LSAMO Link SOM
Already discussed the need for developmental support Also the content of that described during the interview and again at the round table This was put in writing to TM Developmental Support programme for TM Plan to meet in 2 months to discuss reflections and completion of the developmental support package Also one action identified to develop a training package for all midwives on intermittent auscultation (commenced by TM).
Appendix 7 Sent to LSAMO & link SOM for SOM investigations
Writing the investigation report
Section 4 – This should contain an analysis of all the information you have seen and heard. It should be structured, analytical, balanced and objective. The reader should have a full understanding of the evidence you have found and what your analysis is based upon It should come to a conclusion about what your opinion is in relation to the investigation. Facts found or not. Evidence seen or not.
Mitigation – why did she practise in this way? Are there system failures? Rare that there are no mitigating factors
Investigation report- Recommendations
Currently under review
Must always show a direct link to the conclusions you have reached in the earlier section. Cannot introduce something new No action – rare Local action – reflection with named SOM or similar work. Should be documented by SOM in supervisory file Developmental support – for minor, non-recurring mistakes. Should have objectives and be time limited. Named SOM undertakes support and notifies investigating SOM of completion of actions
Investigation report- Recommendations
Supervised practice – Should be used when there are serious concerns about the midwife’s attitude or safety of their practice. Competence is in question as a result of serious or recurring errors in practice, or a midwife lacks insight into her shortcomings or fails to take action to improve skills and knowledge. Not the same as intractable lack of competence or misconduct Referral to the NMC
Summary Report to the HOM/Telling the midwife Summary report Why not the full report?
Who ‘owns’ the reports?
Summary report should contain sufficient information that the HOM can understand what happened, why it was investigated, why it happened, and the rationale behind your recommendations Telling the midwife: Full report, full explanation of her part in the incident/investigation
Evidence to support allegations
Failure 1 I allege that MW Smith failed to recognise the role of patients and clients as partners in their care and the contribution they can make to it.
Alleged breach of Code
.
Evidence Within the letter from the patient .....(Letter App 1) The transcript from the parents....(App 2) MW Smith’s statement of May 20 th statement App 3) says that...... (Midwife Smith MW Smith reiterates the above in her interview of 23 June and that her usual practice is to ....... (Interview notes App 4)
Evidence to support allegations
An audit of MW Smiths records from 10 other cases shows that her usual practice appears to be .....(Records audit summary App 5) Statements from other midwives/interviews show that....(App 6) Midwife Smith’s understanding of her accountability as demonstrated in the interview shows that....
On the balance of probabilities, did it happen.......
Evidence to support allegations
Failure 2 I allege that MW Smith failed to provide an appropriate standard of care in labour by not adequately monitoring fetal well being.
Alleged breach of Midwives Rules – Rule 6 Relevant section of the Code
Evidence Within the notes the fetal heart was not recorded every 15 minutes , specifically at xx, xx and xx hours. (Labour notes App 1) The Trust policy dated xx states that NICE Guidance should be followed regarding auscultation of the fetal heart. (Policy App 2) MW Smith’s statement of (Date) says that she did undertake further observations but did not record them (Statement App 3)
Evidence to support allegations
MW Smith reiterates the above in her interview of xx date and that her usual practice is to take and record the fetal heart according to trust guidelines (Interview notes App 4) An audit of MW Smiths records from 10 other cases shows she does not consistently record fetal observations according to trust policy (Records audit summary App 5) Midwife Smith’s understanding of her accountability as demonstrated in the interview shows that....
On the balance of probabilities, did it happen.......
Create some objectives for Midwife Smith
FTP 2010-2011
667,072 registrants (March 2010) Referrals in 2010/11 - 4,211 (2,215 sent for investigation) This represents 0.6% of registrants 41% referred from employers 23% from police 23% from the public (16% in 2009/10) 13% other referrals 2% from other health professionals
Conduct and competence committee outcomes, 2010-11 647 cases referred to Conduct & Competence Committee 246 hearings Striking off order – 187 (76% of above number of hearings) 0.02% of total register Caution order 100(40%) Conditions of practice order – 39 (15%) Suspension – 89 (36%) Fitness to practise not impaired - 76 (30%) Restoration to register - 4 (6%) Please read NMC Annual Fitness to Practise Report 2010-11 for more details on all of this information
Range of issues
Dishonesty – 25% Patient abuse/inapp relationship – 22% Lack of competence – 24% Failure to maintain adequate records – 4% Other practice related issues (unsafe)– 7% Drugs (mal-admin/theft) - 2% Management practices -2% Failure to collaborate with colleagues/abuse –3% Accessing porn- 4% Violence – 4% Serious motoring offences – 2% Substance misuse – 3% Other (convictions)– 5%
Hints and Tips for SOM’s
Ensure that documentation is clear and logical – pages numbers etc.
Accurate evidence, signed by registrant etc Ensure that standards are followed- if system falls down anywhere it is likely that the panel will notice. It is better to address this at the time than the case be affected. Examples include limited experience due to quiet clinical area, poor supervision, lack of sensitivity towards supervised midwife, no orientation period in new area.
Academic work- ensure midwife knows how it will be marked, to what level required, that they are able to update study skills, given feedback.
Keep records of ALL communication Being a witness – behaviour, no collaboration, read statement, be prepared to be contradicted. Time management at hearings Media attention