Being Open Procedure

This procedure forms part of the Being Open Policy - 033

This procedure forms part of the Being Open Policy

1. Principle

The Trust’s approach to Being Open upholds the following principles

1.1. Principle of acknowledgement

All patient safety incidents should be acknowledged and reported as soon as they are identified. In cases where the service user and/or their carers inform healthcare staff when something untoward has happened, it must be taken seriously from the outset. Any concerns should be treated with compassion and understanding by all healthcare staff. Denial of a service user’s concerns will make future open and honest communication more difficult.

1.2. Principle of truthfulness, timeliness and clarity of communication

Information about a patient safety incident must be given to service users and/or their carers in a truthful and open manner by an appropriately nominated person. Service users should be provided with a step-by-step explanation of what happened, that considers their individual needs and is delivered openly. Communication should also be timely: service users and/or their carers should be provided with information about what happened as soon as practicable.

It is also essential that any information given is based solely on the facts known at the time. Staff should explain that new information may emerge as an incident investigation is undertaken, and service users and/or their carers should be kept up-to-date with the progress of an investigation.

Service users and/or their carers should receive clear, unambiguous information and be given a single point of contact for any questions or requests they may have. They should not receive conflicting information from different members of staff, and using medical jargon which they may not understand should be avoided.

1.3. Principle of apology

Service users and/or their carers should receive a meaningful apology – one that is a sincere expression of sorrow or regret for the harm that has resulted from a patient safety incident. This should be in the form of an appropriately worded and agreed manner of apology, as early as possible. Both verbal and written apologies should be given. Based on local circumstances, a decision will be made on the most appropriate member of staff to issue these apologies to service users and/or their carers. The decision should consider seniority, relationship to the patient, and experience and expertise in the type of patient safety incident that has occurred.

Verbal apologies are essential because they allow face-to-face contact between the service user and/or their carers and the healthcare team. This should be given as soon asstaff are aware an incident has occurred. A written apology, which clearly states the healthcare organisation is sorry for the suffering and distress resulting from the incident, must also be given. It is important not to delay for any reason, including: setting up a more formal multidisciplinary Being opendiscussion with the service user and/or their carers; fear and apprehension; or lack of staff availability. Delays are likely to increase the service user’s and/or their carer’s sense of anxiety, anger or frustration.

1.4.Principle of recognising service user and carer expectations

Service users and/or their carers can reasonably expect to be fully informed of the issues surrounding a patient safety incident, and its consequences, in a face-to-face meeting with Trust representatives. They should be treated sympathetically, with respect and consideration. Confidentiality must be maintained at all times. Service users and/or their carers should also be provided with support in a manner appropriate to their needs. This involves consideration of specialcircumstances that can include a patient requiring additional support, such as an independent patient advocate on a translator. Where appropriate, information on the Trust’s Patient Advisory and Liaison Service (PALS) should be given to the patient as soon as it is possible and other relevant support groups like Cruse Bereavement Care and Action against Medical Accidents (AvMA)

1.5.Principle of professional support

The Trust will aim to create an environment in which all staff, whether directly employed or independent contractors, are encouraged to report patient safety incidents. Staff should feel supported throughout the incident investigation process because they too may have been traumatised by being involved. They should not be unfairly exposed to punitive disciplinary action, increased medico-legal risk or any threat to their registration.

To ensure a robust and consistent approach to incident investigation, the Trust will follow its established HR policies and may consider use of the National Patient Safety Agency’s Incident Decision Tree, which is an an aid to improve the consistency of decision making about whether human error or systems failures contributed to an incident.

Where there is reason for the Trust to believe a member of staff has committed a punitive or criminal act, the organisation should take steps to preserve its position, and advise the member(s) of staff at an early stage to enable them to obtain separate legal advice and/or representation.

Staff will also be encouraged to seek support from relevant professional bodies such as the General Medical Council, RoyalColleges, the Medical Protection Society, the Medical Defence Union and the Nursing and Midwifery Council.

1.6.Principle of risk management and systems improvement

Root cause analysis (RCA), critical incident analyses or similar techniques will be used to uncover the underlying causes of a patient safety incident in accordance with the Trust’s Incident Reporting Policy. Investigations will focus on improving systems of care, which will then be reviewed for their effectiveness.

1.7.Principle of multidisciplinary responsibility

The Trust supports multidisciplinary involvement in the Being Open process and in its investigative processes and expects all clinical, professional and managerial opinion leaders to champion this approach and participate in incident investigation and clinical risk management.

1.8.Principle of clinical governance

Being openrequires the support of patient safety and quality improvement processes through clinical governance frameworks, in which patient safety incidents are investigated and analysed, to find out what can be done to prevent their recurrence. These processes are well established in the trust and there is a clear system of accountability through the chief executive to the board to ensure identified changes are implemented and their effectiveness reviewed. There is a commitment that such findings should be disseminated to staff so that there is wide learning from patient safety incidents and that the Trust should be pro-active in seeking feedback from patients who have experienced Being Open procedures.

1.9.Principle of confidentiality

The Being Open approach will give full consideration of, and respect for, the service user’s and/or their carer’s and staff privacy and confidentiality. Details of a patient safety incident will at all times be considered confidential. The consent of the individual concerned should, whenever possible, be sought prior to disclosing information beyond the clinicians involved in treating the patient, the managers responsible for the delivery of services and the Trust risk management department. Where this is not practical, or an individual refuses to consent to the disclosure, it may still be lawful if justified in the public interest, or where those investigating the incident have statutory powers for obtaining information.

In addition, it is good practice to inform the patient and/or their carers about who will be involved in the investigation before it takes place, and give them the opportunity to raise any objections.

1.10.Principle of continuity of care

Service users are entitled to expect they will continue to receive all usual treatment and continue to be treated with dignity, respect and compassion. If a service user expresses a preference for their healthcare needs to be taken over by another team, then every effort should be made to accommodate this, in accordance with established Trust procedures.

2. Meeting Service Users’ and Staff Needs following a Patient Safety Incident

Whilst discretion will always need to be exercised as to how best to meet individual’s needs following a patient safety incident, the following framework should be adhered to.

2.1.Effective Communication

Following the need to utilise Being Open procedures, the Trust undertakes to communicate effectively by identifying all relevant stakeholders (patients, carers, family members, staff, GP and other healthcare organisations) and put in place relevant immediate and ongoing communication strategies. This will include:

ensuring early identification of, and consent for, the service user’s practical and emotional needs. This includes the names of people who can provide assistance and support to a service user, and to whom the service user has agreed that information about their healthcare can be given. This person (or people) may be different to both the service user’s next of kin and from people who the service user had previously agreed should receive information about their care prior to the patient safety incident. It is important to identify at the outset any special restrictions on openness that the service user would like the healthcare team to respect. It is also important to identify whether the service user does not wish to know every aspect of what went wrong, to respect their wishes and reassure them this information will be made available if they change their mind later on;

• providing repeated opportunities for the service user and/or their carers to obtain information about the patient safety incident;

• providing information to patients in verbal and/or written format;

• providing assurance that an ongoing care plan will be developed in consultation with the service user and will be followed through;

• providing assurance that the service user will continue to be treated according to their clinical needs and that the prospect of, or an actual dispute between, the service user and/or their carers and the healthcare team will not affect their access to treatment;

facilitating inclusion of the service user’s carers or significant others in discussions about apatient safety incident where the service user agrees;

providing carers and those very close to the service user with access to information to assistin making decisions if the service user is unable to participate in decision-making or if theservice user has died as a result of an incident. This should be done with regard toconfidentiality and in accordance with the service user’s instructions;

determining whether there is a need to represent this information to the patient at different times to allow them to comprehend the situation fully;

ensuring families and carers are provided with known information, care and support if a service user has died as a result of a patient safety incident, including referral to the Coroner.

ensuring that discussions with patients and/or their carers are documented and that information is shared with them;

ensuring the service user and/or their carers are provided with information on the complaintsprocedure if they wish to have it;

ensuring the service user and/or their carers are provided with information on the incidentreporting process;

ensuring the service user’s account of the events leading up to the patient safety incident are fed into the incident investigation, whenever applicable;

ensuring the service user and/or their carers are provided with information on how

improvement plans derived from investigations will be implemented and their effects monitored;

developing a system for monitoring and auditing the service user’s perceptions of the being openprocess and ensure their comments are fed back to staff.

2.2.Advocacy and Support

Service users and/or their families and carers may need considerable practical and emotional help andsupport after experiencing a patient safety incident. The most appropriate type of support may vary widely between service users and/or their carers. It is therefore important to discuss their individual needs with the service user and/or their carers. Support may be provided by service user’s families, social workers, religious representatives and Trust services such as the Patient Advice and Liaison Service (PALS).

Where the service user needs more detailed long-term emotional support, advice should be provided on how to gain access to appropriate counselling services, for example, from Cruse Bereavement Care and Action against Medical Accidents.

Through access to PALS services, the Trust will provide:

information on services offered by all the possible support agencies (including their contact details) that can give emotional support, help the patient identify the issues of concern, support them at meetings with staff and provide information about appropriate community services;

contact details of a staff member who will maintain an ongoing relationship with the

service user, using the most appropriate method of communication from the service user’sand/or their carer’s perspective. Their role is to provide both practical and emotionalsupport in a timely manner;

 information on the Being open process in the form of a short leaflet explaining what

to expect;

information on how to make a formal complaint and/or any other available means of

giving positive or negative feedback to healthcare staff involved in their care.

In the case of homicides committed by service users of the Trust, the Trust will offer externally sourced advocacy support to the immediate family of the victim affected by the tragedy in relation to the consequences of the homicide. The offer of this provision will be over and above any ongoing care and support the Trust may be providing itself.

2.3.Accommodating Particular Service User Circumstances

The approach to being open may need to be modified according to the individual service user’spersonal circumstances. The following gives guidance on how to manage different

categories of patient circumstances.

• When a patient dies

When a patient safety incident has resulted in a service user’s death it is crucial that

communication is sensitive, empathic and open. It is important to consider the emotional state of bereaved relatives or carers and to involve them in deciding when it is appropriate to discuss what has happened. The service user’s family and/or carers will probably need information on the processes that will be followed to identify the cause(s) of death. They will also need emotional support. Establishing open channels of communication may also allow the family and/or carers to indicate if they need bereavement counselling or assistance at any stage.

Usually, the Being open discussion and any investigation occur before the coroner’s inquest. But in certain circumstances it may be appropriate to wait for the coroner’s inquest or post mortem evidence before holding the Being open discussion with the patient’s family and/or carers. In any event an apology should be issued as soon as possible after the service user’s death, together with an explanation that the coroner’s process and Trust’s internal investigative processes have been initiated and a realistic timeframe of when the family and/or carers will be provided with more information. Staff should follow the Incident Policy, the Bereavement Policy and seek advice from senior management on the order of communication if in doubt.

• Children

The National Patient Safety Agency “Being Open” guidance contains specific advice with regard to Being Open to children. The Trust does not currently provide children’s services, but should that position change, the NPSA guidance would be adhered to.

• Patients with mental health issues

The only circumstances in which it is appropriate to withhold patient safety incident information from a patient with mental health issues, is when advised to do so by a consultant psychiatrist who feels it would cause adverse psychological harm to the patient. However, such circumstances are rare and a second opinion (by another consultant psychiatrist) would be needed to justify withholding information from the patient.

Apart from in exceptional circumstances, it is never appropriate to discuss patient safety incident information with a carer or relative without the express permission of the patient

• Patients with cognitive impairment

The National Patient Safety Agency “Being Open”. notes:

“Some individuals have conditions that limit their ability to understand what is happening to them. They may have authorised a person to act on their behalf by an enduring power of attorney. In these cases steps must be taken to ensure this extends to decision making and to the medical care and treatment of the service user. The Being open discussion would be held with the holder of the power of attorney. Where there is no such person the clinicians may act in the service user’s best interest in deciding who the appropriate person is to discuss incident information with, regarding the welfare of the service user as a whole and not simply their medical interests. However, the service user with a cognitive impairment should, where possible, be involved directly in communications about what has happened. An advocate with appropriate skills should be available to the patient to assist in the communication process”.

Consideration should be made of the Trust’s Mental Capacity Act Policy.

• Patients with learning disabilities

Where a service user has difficulties in expressing their opinion verbally, an assessment

should be made about whether they are also cognitively impaired (see above). If the service user is not cognitively impaired they should be supported in the Being open process by alternative communication methods (i.e., given the opportunity to write questions down). An advocate, agreed on in consultation with the patient, should be appointed. Appropriate advocates may include carers, family or friends of the patient. The advocate should assist the service user during the Being open process, focusing on ensuring that the service user’s views are considered and discussed.