PFD report

Derek Holmes · Prevention of Future Deaths report

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Issued 22 Jun 2022•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
20

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Delays and unfit processes for obtaining advice from a specialist hospital
  2. Failure to conduct prompt, rigorous and effective investigations of clinical incidents
    Part of recurring concern: Inadequate safety incident investigations
  3. Failure to revisit patient safety incident harm grading
    Part of recurring concern: Unreliable formal safety-incident management processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.18

  1. Action

    Implement Trust-wide witness statement training and develop supporting statement templates.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
  2. Action

    Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
  3. Action

    Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays and unfit processes for obtaining advice from a specialist hospital

Wider context from the report

“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to conduct prompt, rigorous and effective investigations of clinical incidents

Wider context from the report

“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to revisit patient safety incident harm grading

Wider context from the report

“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”

Is this part of a recurring concern?

Yes — Unreliable formal safety-incident management processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate processes to ensure patient call-bells are working at all times

Wider context from the report

“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”

Is this part of a recurring concern?

Yes — Unreliable call bell systems for summoning assistance.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of formal investigation learning to address the breadth of identified patient safety issues

Wider context from the report

“1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: • the adequacy of existing processes designed to ensure patient call-bells are working at all times; and • why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident). ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns; Failure to identify and address recurring safety issues through organisational learning; Unreliable root cause analysis processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement Trust-wide witness statement training and develop supporting statement templates.

Verbatim wording from the response

“Beyond this, to further strengthen internal processes, the Trust are undertaking training to support the development of staff. Witness statement training is being implemented Trust wide to help support those who have been approached to prepare statements. Clinical and nursing staff understand that they may be asked to provide a written report about their involvement in a patient’s care. The training will accentuate that the statement is to focus on the facts relevant to death and is to be detailed and accurate. In order to maintain consistency, templates are being drafted to ensure structure is provided.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 6 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.

Verbatim wording from the response

“The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.

Verbatim wording from the response

“Prior to the inquest of Mr Holmes, I had instructed a review of the Trust’s Incident Reporting and Incident and Complaints Investigation Policy. This was in the context of Patient Safety 2, as information and resources become available to inform the Trust approach. The learning from this inquest has further informed the quality assurance process. The review and update to the Policy has been undertaken by the Head of Investigations, Learning and Audit and Head of Nursing for Professional Standards and Assurance, overseen by the Assistant Director of Integrated Governance.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver comprehensive root cause analysis investigation training for relevant clinical and corporate staff.

Verbatim wording from the response

“The Trust recognise the importance of comprehensive investigation training to underpin the methodology and rigor that must be applied to this process. As such, the Trust are providing root cause analysis investigation training days which commence in September 2022, and”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 1 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement revised call-bell, oxygen and suction checking through a safety checklist, standard operating procedure and auditable oversight.

Verbatim wording from the response

“In relation to the issue raised relating to patient call bells, a safety checklist has been revised with an accompanying standard operating procedure intended to support the regular testing and checks of emergency equipment within all inpatient areas. This includes a daily check by operational staff of the call bell, oxygen and suction located at each bedside. This is overseen by a weekly assessment, recorded within the safety checklist. This is then auditable as part of assessments completed by members of the Safer Care Team for each area and reviewed as part of the Ward accreditation process. As this is a new process, this has been socialised with the divisional leadership teams to ensure their views and comments are considered in the implementation of this.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 6 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.

Verbatim wording from the response

“The Trust has also introduced a bimonthly oversight meeting for triangulation of scheduled and new inquests with existing or newly instructed investigatory processes, with Head of Investigations, Audit and Learning, Head of Assurance, Compliance and Governance, Head of Nursing for Professional Standards and Assurance and Legal Services Manager, chaired by the Assistant Director of Integrated Governance. This process has sought to ensure the improved triangulation of current investigations and support early identification of any changes in status to the patient (such as their death) or delays in conclusion. Patient tracking list methodology will be used to inform this process and ensure that there is oversight of all learning activity associated with investigations and inquests.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.

Verbatim wording from the response

“The development of a clinical review process is ongoing at the time of preparing this response to ensure that all incident investigations, inquest statements and reviews undertaken as part of our learning from deaths process are assessed and considered cohesively before an inquest. This aims to ensure consistency across all streams of investigation and learning and will help provide an additional clinical check to ensure that any potential discrepancies are responded to, enhancing our approach to learning.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Quality-assess falls-pathway investigations against clinical and nursing records before assurance-panel review.

Verbatim wording from the response

“The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.

Verbatim wording from the response

“The Trust are currently undertaking a comprehensive improvement project focused upon the Ulysses Safeguard system, which is the electronic risk management system used by the Trust. It is a system which allows for web-based reporting of incidents and safeguarding concerns, alongside system based operational management of complaints, incidents, claims, inquests, safeguarding and risk. It is also a platform which has the facility to recognise and acknowledge good professional practice known as ‘Excellence reporting’. The improvement project aims to increase utility of this system, with standardisation of use and increased reporting functionality.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require appropriate Matron review and approval of investigations through the revised Safer Care Assurance Process.

Verbatim wording from the response

“In regard to the errors identified within the root cause analysis, steps have been taken following the inquest of Mr Holmes to strengthen the process in which these documents are checked for quality and factual accuracy, with increased divisional ownership and oversight. The Safer Care Assurance Process has been revised to explicitly include the expectation for all investigations of this form to be reviewed and approved as an accurate account of the incident and learning by an appropriate Matron. Although it is not possible to completely remove the human factors which can affect this process, it is anticipated that this should reduce the opportunity for errors such as those identified in the root cause analysis document presented in relation to Mr. Holmes.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate organisational learning on investigation methodology and responding to people who raise concerns.

Verbatim wording from the response

“The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a live register of staff who have completed root cause analysis investigation training.

Verbatim wording from the response

“The training has been targeted initially to key members of clinical and corporate teams who are likely to undertake root cause analysis or complaints investigations as part of their role. Once undertaken the Integrated Governance Team will hold a live register of staff who have completed root cause analysis investigation training. This is to ensure that on the commissioning of any new investigation, at least one member of the team has completed this training.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide the updated investigator toolkit to each root cause analysis investigation team.

Verbatim wording from the response

“Overseen by the Head of Investigations, Learning and Audit a resource tool kit for investigators has been reviewed an updated to include guidance on triangulation, factual accuracy and a data mapping tool which should be included as part of the investigation process. The tool kit will be provided to each investigation team at the commencement of a root cause analysis investigation.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Add a full-time clinical staff member to support the strengthened inquest triage and review process.

Verbatim wording from the response

“As part of the new process, a clinical review of the case and a review of any previous investigations is also performed at the outset where we are able, in order to identify any linked actions. This process would allow for the revisiting of levels of harm for individual incidents to ensure that this is appropriate, with advice from the specialist teams. There is also the addition of a full time clinical member of staff to support this process moving forward, and a more rigorous review system to capture potential delays. The Trust has started to implement this process ensuring communication is maintained with HM Coroner throughout.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 7 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require review of root cause analysis requests by senior nursing and governance leaders when a patient dies during investigation.

Verbatim wording from the response

“In addition to this, the Safer Care Assurance Process also includes a caveat that the request for root cause analysis is reviewed by the Head of Nursing and Assistant Director of Integrated Governance should the patient die during the investigation process. This is intended to provide an opportunity to stop and reassess whether continuation of the enquiries is the most appropriate cause of action, or whether an additional or more comprehensive form of investigation is required.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct ongoing local audits to monitor adherence to the complaints and investigation policy.

Verbatim wording from the response

“The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.

Verbatim wording from the response

“To provide an additional safety net in this process, the Trust has also taken steps to amend and improve the triage system for newly listed inquests. In the context of the recent letter HM Senior Coroner received from Mr Richard Jolly of Weightmans LLP, in relation to the provision of our inhouse legal team, processes have been reinvigorated to ensure triage, review and instruction sent out to clinicians within seven days of the initial inquest request.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 7 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate a briefing on triangulation and factual accuracy in investigations across the Trust.

Verbatim wording from the response

“The Trust has used the case of Mr Holmes and subsequent learning to develop a seven minute briefing which has been shared widely across the Trust, to reemphasise the importance of triangulation and accuracy of data used within any investigations including root cause analysis and complaints.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.

Verbatim wording from the response

“Whilst basic training has been provided for Trust members of staff in incident management over the last two years and support has been offered, and comprehensive, individual and bespoke support has been provided to individuals completing investigations, the delivery of largescale comprehensive investigation training has been challenging in the context of Covid and the Covid response. The reasons for this are twofold; both in terms of the redeployment of key members of the corporate governance team to support clinical areas, and in terms of the ability of staff to attend, when the training is not mandatory.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 1 · response
Published 22 September 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Discuss development and integration of an automated referral-tracking system that generates waiting-time reports and notifications.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
  2. 2

    Update informal learning and training on complaint investigation and create an investigator role description.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Changes or developments to the external referral process would be led by receiving centres such as Wrightington, Wigan and Leigh NHS Foundation Trust.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss development and integration of an automated referral-tracking system that generates waiting-time reports and notifications.

Verbatim wording from the response

“This process is recorded using a database and is pursued manually by the Trauma Coordinators on a daily basis for confirmation of an available bed and allocation of a theatre date. I am advised that as centres such as Wrightington, Wigan and Leigh NHS Foundation Trust receive referrals from across Greater Manchester, any changes or developments to this process would be led by them. However, it is considered that there is an opportunity for the Trust to further”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 6 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update informal learning and training on complaint investigation and create an investigator role description.

Verbatim wording from the response

“Learning The Trust has held a learning from complaints stakeholder event with senior leadership colleagues from across the organisation to review current processes for learning. This event reviewed the learning that had been identified in relation to complaints investigations and what was needed to strengthen and support the completion of investigations resulting from complaints. The Complaints and Concerns policy was reviewed and a number of additional actions were agreed such as updating informal learning and training on complaint investigation and writing a role description to support investigators. This includes ensuring that evidence reviewed as part of the investigation process is clearly referenced to ensure that there is oversight of this when completing responses.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 22 September 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Changes or developments to the external referral process would be led by receiving centres such as Wrightington, Wigan and Leigh NHS Foundation Trust.

Verbatim wording from the response

“This process is recorded using a database and is pursued manually by the Trauma Coordinators on a daily basis for confirmation of an available bed and allocation of a theatre date. I am advised that as centres such as Wrightington, Wigan and Leigh NHS Foundation Trust receive referrals from across Greater Manchester, any changes or developments to this process would be led by them. However, it is considered that there is an opportunity for the Trust to further”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 6 · response
Published 22 September 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026