Arthur Hughes

Ein cyf / Our ref: INC142329 

Eich cyf / Your ref:   

:  01978 727463 

Gofynnwch am / Ask for: 

E-bost / Email: 

Dyddiad / Date:  04 May 2020  

PRIVATE & CONFIDENTIAL 

Mr John Gittins 
H.M. Coroner for North Wales  
(East and Central) 
County Hall 
Wynnstay Road  
Ruthin, Denbighshire 
LL15 1YN 

Dear Mr Gittins,  

REGULATION 28 RELATING TO MR ARTHUR PRICE HUGHES 

I am writing further to the recent Regulation 28, Prevention of Future Deaths Notice, issued to 
the Health Board following the inquest touching upon the death of Mr Hughes.  

I would like to begin by extending the sincere condolences and apologies of both myself and 
the Health Board to the family of Mr Hughes. We fully accept the findings of the inquest and 
we deeply regret that we did not meet the standards that we expect of ourselves. We have 
used the findings of the inquest to review and improve the quality and safety of our services.  

Please find below our response to your concerns which I trust will provide you with assurance 
about how we intend to strengthen our processes to avoid a reoccurrence of the issues you 
have identified. We are committed to continually improve the quality and safety of our services 
and I hope the below conveys this. 

The concerns you raised were: 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 

Swyddfa'r Gweithredwyr / Executives’ Office, 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

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 Ysbyty Gwynedd, Penrhosgarnedd, Bangor,  Gwynedd, LL57 2PW ----------------------------------    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 Our response: 

1. Appointment of Locum Medical Staff – Assessment of practice 

A  Standard  Operating  Procedure  (SOP)  had  been  revised  and  implemented  previously  as 
reported during the inquest. The SOP required clinical departments to undertake the following 
for all locum appointments (both fixed term contracts and agency locums). 

1.  Undertake a Local Induction to be completed by the end of the first shift and submitted 

no later than 3 days following the first shift. The Local Induction includes 

  Practical arrangements 
  Key Health Board Policies 
 
  Confirmation of minimum period of supervised practice (if applicable) 

Initial outline of expectations of the post and limitations against the role 

2.  Undertake an Assessment of Practice and Performance – This assessment includes: 

  Clinical Skills 
  Knowledge 
  Attitudes 
  Relationships 
Integrity 
 

The SOP required retention of documentation by the clinical department. 

An audit of compliance had been undertaken in relation to the two requirements above against 
appointments (18 placements) made following revision of the SOP in 2019. 

Whilst Clinical Directors confirmed that the requirement for Local Induction had been met, not 
all were able to provide the documentary evidence required. 

Clinical Directors also confirmed that ongoing assessment of practice and performance was 
undertaken and where issues were identified, these had been escalated as appropriate through 
the  Office  of  the  Medical  Director/Responsible  Officer  and/or  the  relevant  Agency  provider 
Responsible  Officer.  However,  the  specific  pro  forma  required  by  the  SOP  had  not  been 
completed for all placements. 

Action taken to date: 

i. 

Immediate  action  was  taken  to  obtain  assurance  from  each  of  the  relevant  Clinical 
Directors  regarding  the  capability  and  performance  of  each  of  the  12  individuals 
remaining in the Health Board – this has been completed.   

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 ii. 

iii. 

In  addition  to  the  immediate  assurance,  Clinical  Directors  were  asked  to  provide 
completed assessment forms for each of the individuals – original due date 31 March 
2020; 
The  Standard  Operating  Procedure  (SOP)  has  been  amended  to  ensure  central 
collection  and  follow  up  of  both  Local  Induction  and  Assessment  of  Practice  and 
Performance pro forma – due to be implemented 01 April 2020; 

iv. 

Locum  Induction  pro  forma  now  to  be  submitted  to  the  Medical  Bank  Service  with 
payment not processed until received – original due date 01 April 2020; 

v.  Assessment  of  Practice  and  Performance  pro  forma  required  by  the  tenth  day  of 
placement, signed by the Clinical Director and submitted to the Medical Bank Service – 
original due date 10 April 2020; 

vi.  Compliance  and  action  taken  to  remedy  non-compliance  with  both  requirements 
included  in  the  monthly  Medical  Agency  Locum  Report  to  the  Executive  Director  of 
Workforce and Organisational Development and Board Committee – original due date 
28 April 2020.  

The  original  implementation  dates  for  the  actions  above  have  been  delayed  due  to  the 
activation  of  the  Major  Incident  Response  to  COVID-19.  However,  revised  implementation 
dates have been set to ensure documentary evidence requirements are in  place by 31 May 
2020 with reporting by 30 June 2020. 

In the intervening period, Clinical Directors are required to provide verbal/email confirmation 
that individuals working under their supervision (accountability) are competent to do so. 

We apologise for the concerns identified in our recruitment process and we are sorry that we 
were  unable  to  offer  greater  assurance  to  you  at  the  inquest.  I  trust  the  above  actions 
demonstrate our continued commitment to improvement.  

2. Reference validation 

The  Health  Board  is  required  to  follow  the  NHS  Employment  Check  Standards  for  both 
employees and Agency workers. 

The NHS Employment Check Standards include the requirement to: 

i.  Obtain factual references covering the last 3 years employment and specifically from 

the current or most recent employer; 

ii.  Current or most recent employer reference must be from the line manager; 
iii.  References must be written and sent from a recognised company email address; 
iv.  They should include the referee’s name, job title and a main landline number. 

Action taken to date: 

Following  the  review  undertaken  as  a  result  of  the  inquest,  the  following  process  has  been 
developed  to  ensure  that  any  issues  or  anomalies  are  addressed  prior  to  a  formal  offer  of 
employment being issued: 

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 i.  Application forms for shortlisted candidates will be screened by the central Recruitment 
Team prior to interview to ensure that referees provided include the current/most recent 
line manager;  
This screening will identify any irregularity with the candidate and confirm that this must 
be addressed prior to interview or invitation will be withdrawn; 

ii. 

iii.  Were  permission  to  contact  referees  is  granted,  references  must  be  sought  prior  to 
interview  and  any  issues,  irregularities  highlighted  to  the  chair  of  the  panel  prior  to 
interview; 

v. 

iv.  Chair  of  the  panel  to  seek  clarification  from  candidate  either  prior  to  interview  if  the 
matter  is  sensitive  in  nature  (i.e.  could  be  considered  to  be  prejudicial  or  personally 
sensitive) or as part of the interview, responses for both must be recorded in writing; 
In  the  event  that  the  panel  requires  additional  validation  of  information  provided  in 
relation to competence or performance, the chair of the panel may contact the referee 
provided either by email or telephone to seek further assurance, this information must 
be recorded in writing;  
In the event that the candidate is an agency worker, the chair of the panel may contact 
the  Responsible  Officer  for  the  agency  copying  in  the  Health  Board’s  Responsible 
Officer. 

vi. 

The additional elements of this process were due to be reviewed, approved and implemented 
from  01  April.  However,  this  has  been  delayed  due  to  the  activation  of  the  Major  Incident 
Response to COVID-19. 

At this point the Health Board is following the temporary pre-employment check requirements 
set out by NHS Employers during the COVID-19 pandemic. Appropriate risk assessments are 
undertaken for appointments made during this period. 

Subject to the continuation of these temporary standards, the Health Board would intend to 
implement  the  revised  process  from  01  June  2020.  An  audit  will  be  carried  out  at  3  and  6 
months post-implementation to give us assurance that this has been effectively embedded into 
practice. 

We regret that the appropriate references were not taken up as identified at the inquest and I 
trust  the  above  provides  assurance  that  our  process  has  been  strengthened  and  is  in 
accordance with NHS standards.  

Conclusion: 

As mentioned above, we fully accept the findings of the inquest.  I would like to reiterate the 
condolences and apologies of the Health Board to the family of Mr Hughes. We deeply regret 
that there were concerns in our processes and we apologise for this. We are equally sorry for 
the distress that must have been caused throughout this inquest process.  

We have used the findings of the inquest to improve our services and I hope that our response 
provides confidence to you and Mr Hughes’s family that we have acted upon your findings at. 
The actions above will be tracked by our Quality Assurance Department to ensure that they 
are completed, and this will be reported to our Board.  

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 If  you  require any further information  or wish  to  discuss  this  letter  please do not  hesitate  to 
contact Matthew Joyes, Acting Associate Director of Quality Assurance.  

Yours sincerely  

Mrs Gill Harris  
Deputy Chief Executive 
Executive Director of Nursing and Midwifery 

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