Date: 26th September 2013

TRUST BOARD IN PUBLIC

Agenda Item: 4.1

REPORT TITLE: Significant Risk Register

Gillian Francis-Musanu
EXECUTIVE SPONSOR:
Director of Corporate Affairs
Colin Pink
REPORT AUTHOR:
Corporate Governance Manager
AAC 2nd September 2013
REPORT DISCUSSED PREVIOUSLY:
Management Board, Quality & Risk
(name of sub-committee/group & date)
Executive Team 18th September 2013
Purpose of the Report and Action Required: (√)

To provide assurance to the Board on the Approval

management of the Strategic Risk Register and Discussion √
actions taken to reduce or mitigate risks.
Information/Assurance √
Summary: (Key Issues)

The Significant Risk Register details all risks on the Trust risk register system that are
recorded as significant and the inks to the Board Assurance Framework.

Relationship to Trust Corporate Objectives & Assurance Framework:

This report should be read in conjunction with the Board Assurance Framework.

Corporate Impact Assessment:

The report is a requirement for all NHS
Legal and regulatory implications
organisations.
Financial implications Information in migrating actions
As described throughout, focussing on patient
Patient Experience/Engagement
safety
Risk & Performance Management These are highlighted throughout the report.
NHS Constitution/Equality &
N/A
Diversity/Communication
Attachments:

Significant Risk Register

Page 1 of 3 Version 1
TRUST BOARD REPORT – 26th September 2013
BOARD ASSURANCE FRAMEWORK

1.0 Introduction

This paper provides a supporting narrative for:

– The Trust wide significant risk register (Specifically all current risks of 15 or
above).

The significant risk register (SRR) is reviewed by the Management Board for Quality
and Risk (MBQR) on a quarterly basis and more specifically by the Divisions who
scrutinise their divisional risk registers on a more frequent basis as part of their
governance review meetings. The Executive also provide a role in reviewing and
moderating the Significant Risk Register.

A significant exercise has been carried out to liaise with owners of all risks on the
significant risk register. This focus has been on reviewing risks to ensure:

 Risks are in review date where possible

 Risk scoring is aligned across the Trust (In progress, some homogeneity has
been established)
 Mitigating actions are reviewed and implemented
 Increase linkages between the Board Assurance Framework and the SRR

The Trust acknowledges that there is a need to focus on the development of the
significant risk register and this will be undertaken over the next few months.

2.0 Significant Risk Register

The Trust significant risk register is attached for information. This details all current
red risks (scoring 15 or above). There are currently 16 risks that fall into this
category.

Significant risks fall into the current categories:

Risk type Number

Patient Safety 8
Financial Management 3
Quality of Service 1
ICT Infrastructure 1
Pt 'experience' & Care Pathways 1
Key Performance Targets 1
Infection Control 1
Grand Total 16

Seven of these risks are specifically linked to the Board Assurance Framework
detailed below:

Page 2 of 3 Version 1
 ID Title BAF Risk
1050 Failure to achieve stretch 1.1f Failure to maintain systems to
target for CDI reduction control rates of HCAI will effect patient
safety and quality of care
1051 Patient admitted to the right 1.3a If the Trust does not maintain and
bed first time improve ability to allocate the right bed
first time there is an increased risk of
receiving poor quality of our care
(effectiveness, experience and safety)

1453 Orthopaedic wards at risk of 4.4b There is a risk that the Trust isn’t
non compliance with key able to deliver service in an effective
national standards due to timely manner due to the estate not
environmental challenges fully supporting the clinical strategy

1459 Poor liquidity ratio impacting 4.1d Liquidity: Inability to pay creditors
on cash position / staff resulting from insufficient cash
due to poor liquid position

1477 Medical Division Expenditure 4.1b Failure to stop divisional

Budget Overspend overspending against budget
1479 Risk on Income Target from 4.1a Failure to deliver income plan
Contract Challenges
1491 Failure to maintain 1.1c Failure to maintain Emergency
Emergency Department Department performance because of
performance lack of capacity in health system to
manage winter pressures has a
significant impact on the Trust's ability
to deliver high quality care

3.0 Summary and further actions

The board is asked to note the content of the significant risk register.

Further work will be required to ensure the significant risk register describes the full
range and breadth of the risks the Trust is managing / mitigating. This work is
ongoing and will be undertaken over the next few months

Colin Pink
Corporate Governance Manager
September 2013

Page 3 of 3 Version 1
 Risk Type
Specialty
ID
Open Date
Directorate

Initial Rating
Current Consequence
Current Likelihood
Current Rating

Residual Rating
Next Review
Title Description Existing controls Treatment Plan Due date Done
Trauma & Orthopaedics date
Patient Safety
SURG
1453
13/06/2013

31/10/2013
Orthopaedic wards at risk Due to the current state of the fabric and enviroment within Newdigate Developed a SSIS action plan which 20 4 5 20 1)Raise at ward improvement group 2)Agreed Capital Plan 3)Agreed date 02/07/2013 02/07/2013 8
of non compliance with and Leigh wards there is a risk of the Trust being unable to comply considers all stages within the patient to commence decorating and refurbishment 02/07/2013 31/08/2013
key national standards with some key national standards. Through surgical site infection journey Working with house keeping 30/09/2013 18/09/2013
due to enviromental audits audits it has been identified that this group of orthopaedic teams to increase level of cleaning as
challenges patients are at risk of acquiring a post op wound infection due to the necessary Managing placement of
following reasons : Not all bed spaces have O2 points which results in patients within identified single sex bays
frequent patient moves within the ward. Storage on the ward is limited this at times results in the redesignation
and therefore 'socially clean' equipment is stored in inappropriate of male and female bays resulting in
areas Ensuring that the ward is visibly clean is difficult due to poor multiple bed moves
wear and tear of the walls, doors, flooring and ceilings. There is a risk
of breaching the delivery of single sex accomodation standard due to
ward bays not having access to seperate toilets and bathroom
facilities.
MEDIC

Financial Management
General Medicine
1477
19/07/2013

30/09/2013
Medical Division There is a risk of finacial overspend in the Medical Division at year Nursing weekly agency & vacancy review 20 4 4 16 Contingency plans devloped to address saving plans describded on the 31/08/2013 12
Expenditure Budget end, due to significant cost pressures related to temporary staffing by matron. Monthly budget clinics with board assurance framework
Overspend levels, medical and surgical non-pay and drug re-charges. Any Divisional Cheif Nurse, finance & Matron.
actions to reduce this overspend may result in reduction of service PMO
provision. 268k overspend at M4.
Financial Management Pt 'experience' & Care Pathways
CORP
1491
13/06/2013

30/10/2013
Operations

Failure to maintain Failure to maintain Emergency Department performance because of 1) EDD Patient Pathway 2)Discharge 20 4 4 16 As decribded on the board assurance framework 31/03/2014 12
Emergency Department lack of capacity in health system to manage winter pressures has a management 3) Plans for escalation
performance significant impact on the Trust's ability to deliver high quality care areas agreed and management tools in
place 4) Reviewing all breaches on
weekly to implement lessons learnt
Finance - Fin. Management
CORP
1479
23/07/2013

31/10/2013
Risk on Income Target Risk of loss of income from contract challenges from CCGs Work to contract - contrat operation and 16 4 4 16 As describded on BAF 31/03/2014 9
from Contract Challenges challenge process managed tightly.
Discussions taking place with CCGs over
Section 251 issue - Trust is minded not to
accept the retrospective challenge and is
taking advice from the TDA.
 Risk Type
Specialty
ID
Open Date
Directorate

Initial Rating
Current Consequence
Current Likelihood
Current Rating

Residual Rating
Next Review
Title Description Existing controls Treatment Plan Due date Done
Intensive Care date
Patient Safety
SURG
1484
29/07/2013

10/12/2013
There is a risk to quality There is a risk to patients in ICU overnight and during weekends due The Critical Care Outreach team work 16 4 4 16 1)Review phased recruitment of ICU staff 2)Submit business case for the 14/11/2013 02/08/2013 8
of care for patients in ICU to reduced medical staffing levels from 6 to 2 doctors during this time. alongside ICU to assess and help provide provision of extra out of hours staffing 29/08/2013
overnight and weekends The ICU doctors on duty are often called to other critically ill patients the care to critically ill patients whilst a
around the hospital (wards, ED and operating theatres) leaving ICU bed becomes available on ICU.
patients exposed, as no other medical cover is available there. However,they are seeing multiple patients
throughout the hospital. The Theatre
Anaesthetist on call may also be called
on to assess patients on the ward who
are in need of ICU care, but they have
limited availability.
MEDIC
General Medicine
Patient Safety
1447
06/06/2013

15/10/2013
Risk to achieving Risk to patients safety and quality for the patient in the general area None 16 4 4 16 1)To investigate the possibility of the Haemotology beds being managed 11/10/2013 01/09/2013 6
consistent standards of of the ward balanced against requirments for the nurse in charge as a separate unit. 2)Advertise and recruit a band 7 ward manager 3)To 23/09/2013
care on Godstone administrating and caring for patients recieveing chemotherpy. This is advertise and recruit another band 6 sister with out Chemotherapy 23/09/2013
due to the inability to attract and retain a ward manager(band 7 layout experience 4)Matron to be based on Godstone ward Monday to Thursday 02/10/2013
of ward,and the complex mix of different speciality patients.High
vacancy levels, high use of temporary staff,this leads to delays in
discharge planning and completeion of paperwork, administration of
IV medications,general communication with the MDT, families and the
supervision of juniors.
Quality of Service
Nursing - Strategy & Standards
CORP
1501
01/04/2013

30/10/2013
Patient admitted to the If the Trust does not maintain and improve ability to allocate the right 1) Operational meeting three times a day 84 4 16 As decribded on the board assurance framework 01/04/2014 6
right bed first time bed first time there is an increased risk of receiving poor quality of our chaired by Chief / Deputy Chief Operating
care (effectiveness, experience and safety) Officer with clinical involvement from
Matrons, Nurse Specialists and therapists
2) Daily Board rounds by clinical site
team 3) Live 'To come In' lists available to
view in all specialty wards to encourage
active pull of patients from AMU to the
correct specialty bed 4)Matrons walk
round 5) Additional screens arriving to
reduce chance of mixed sex
accommodation breaches during winter
pressures 6) Matron on site 7 days a
week
Patient Safety Patient Safety
1366
14/09/2012

25/10/2013
Obstetrics

Resuscitaires no longer Potential risk of harm to neonates due to inability to resuscitate with Two compliant resuitation units are 12 4 4 16 1)Equipment purchased and delivery expected in November 01/12/2014 01/12/2014 4
WCH

compliant with national air as current equipment not compliant with current national guidance. currentley being trialled whilst actions to
guidance and are not fit Current equipment uses oxygen rather than air. mitigate the risk are completed.
for purpose
MEDIC
Respiratory
1473
17/07/2013

30/09/2013
Risk of sub optimal NIV Risk of sub optimal non invasive ventilation (NIV) service as this is New Trust NIV policy is in progress 16 4 4 16 1)Ratify NIV policy at Management Board 2)Capital bid approved Audit 30/08/2013 4
service delivered across many differing ward areas due to lack of respiratory against NIV policy 30/04/2014
high dependancy area. This lack of resource has resulted in
avoidable deaths, poor patient experience, non compliance with BTS
guidance and NICE guidance for chronic bronchitis. Current NIV
management plan paperwork is not widely used,due to a lack of
centralisation & co-ordination
 Risk Type
Specialty
ID
Open Date
Directorate

Initial Rating
Current Consequence
Current Likelihood
Current Rating

Residual Rating
Next Review
Title Description Existing controls Treatment Plan Due date Done
date
MEDIC
Oncology/Cancer Services
Patient Safety
1346
14/06/2012

17/10/2013
Insufficient chemotherapy Risk of potential harm and death due to insuffient number of trained Training provided by Chemotherapy 12 4 4 16 1)Send complex chemotherapy protocol patients to tertiary centres 2)co- 30/09/2013 27/08/2013 1
trained nurses on chemotherapy nurses on Godstone ward to provide sickness absence Specialist Nurse to nurses intending to ordinate training to prepare appropriate staff for level three training 3)All 18/12/2012 05/03/2013
Godstone ward. cover and recommended specialist administration of oral undertake degree module & to raise nurses to receive oral drugs training 4)Matron to monitor number of 18/12/2012 27/08/2013
chemotherapy administration. This has the potential to result in drug awareness on the ward among non haematology patients on Godstone & report concerns to CDN 5)Matron 18/09/2013
errors due to unfamilarity with chemotherapy regimes, incorrect chemo trained nurses. to collate the number of times that double checking by two chemotherapy 28/06/2013
administration protocols, poor monitoring, and reporting and drug nurses is not acheived & report to CDN. 6)Proposal paper to be agreed 30/09/2013
error. and presented to Management Board Monitor 7)Incidents and 30/09/2013
Operational Issues Monthly through Divisional Boards
Patient Safety
CSS
1483
24/07/2013

Diagnostic Imaging

31/10/2013
Risk associated with new Following the installation of a new PACs & RiS system on 21st June, Daily and weekly meetings for working 15 4 4 16 1)Select and provide superuser training 2)Training department has 07/09/2013 18/09/2013 1
Cerner PACS and RIS the service has been working with an unstable system due to various group at various levels in place trying to correct training materials and experience 3)Training materials available 07/09/2013 18/09/2013
within DI technical issues. Risk of delays in reporting images and overall address problems. Monitoring all waits at on Trust Intranet 4)Train Radiologists to use new system effectively 5)All 31/10/2013 18/09/2013
productivity with in the Radiology departments on all sites. weekly PTL meetings. Additional non-radiology staff to be trained 6)Refresher training to be provided to 25/10/2013 12/08/2013
reporting sessions by radiologists to Radiology staff 7)Agree workarounds to resolve JNLP arguments 23/08/2013 18/09/2013
cover workload Increased working hours 8)Produce a Radiology 'Crashing' Issues Template 23/08/2013
by all DI staff to complete workload 31/07/2013
12/09/2013
Medical Director's Office Finance - Fin. Management
Financial Management
CORP
1459
01/04/2013

31/10/2013
Poor liquidity ratio Risk of inability to pay suppliers due to lack of cash from the poor 1. Bi weekly review of forward cash flow 25 5 3 15 Day to day cash control is main action currently, coupled with action sto 31/03/2014 12
impacting on cash liquidity ratio. by finance team and CFO 2. Cash and maintain service income and spend Discussion continues with the TDA 31/03/2014
position working capital policy and strategy 3. Long term financial model, and TDA plan now provides additional 31/03/2014
Annual cash plan linked to business plan validation of the level of cash injection required and the interaction from
and capital plan an improving financial position within the model
Patient Safety
CORP
1460
01/04/2013

30/09/2013
Procedures for Risk to patients of DVT/PE arising from incidence of not manging VTE risk assessment carried out on 15 5 3 15 Develop system monitoring occurrence of VTE to be reviewed by 30/09/2013 12
monitoring and reducing risks that are identified on admission. VTE risk assessment carried admission as part of CQUINS programme thromboembolism group
incidence of DVT/PE out on admission
 Risk Type
Specialty
ID
Open Date
Directorate

Initial Rating
Current Consequence
Current Likelihood
Current Rating

Residual Rating
Next Review
Title Description Existing controls Treatment Plan Due date Done
Medical Director's Office date
CORP
1050
01/07/2010

Infection Control

01/10/2013
Failure to achieve stretch Risk to patient health and Trust reputation of failing to deliver DH Trust wide infection control education 16 5 3 15 1)Implement Clinician lead RCAs of all Trust acquired cases 2)HCAI 30/06/2011 09/05/2012 10
target for CDI reduction Cdiff target. initiatives for all staff RCA process Taskforce monitoring: ongoing Repeat Isolation spot check and review at 01/07/2010 01/07/2010
(clinical) for every case. Antibiotic HCAI Taskforce 3)All cases discussed at relevant Divisional Governance 31/07/2010 10/01/2011
Stewardship Programme Trust CDI policy meetings 4)Implement revised stool chart incorporating diarrhoea risk 30/09/2012 30/09/2012
CDI surveillance programme Trust assessment 5)Implement new product cleaning 6)Implement antiobiotic 30/11/2012 27/11/2012
Antibiotic policy Outbreak Control group ward rounds 7)Publish results of KPIs from weekly audits 8)Implement 01/12/2012 01/12/2012
established Hydrogen peroxide cleaning quality ward rounds 9)Carry out a reaudit of isolation processes and 02/04/2012 09/05/2012
Use of Tristel Jet and Fuse Ward facilities 10)Commence Antibiotic Stewardship Group Review possibility 01/05/2012 01/05/2012
cleaning with Tristel Fuse and Tristel Jet of weekly antibiotic ward round Implement trial of 11)Bioquell ICE-PODS 02/04/2012 09/05/2012
Sterinis hydrogen peroxide facilitate Chiefs agreed 12)Taskforce subgroup review of RCAs. 13)Selected 25/02/2011 25/10/2011
improved decontamination of wards Use cases with learning potential to be presented to wider clinical fora. 28/02/2012 02/04/2012
of isolation facilities when available HCAI 14/02/2012 14/02/2012
task force established Weekly saving 15/09/2013 26/07/2013
lives audit prog Antibiotic pharmacist in 30/04/2013
place Increased monitoring and
surveillance from IPCAS and Facilities
during raised incidences Diarrhoea risk
assessment incorporated onto Bristol
Stool chart
Key Performance Targets
Outpatient Services
CSS
1437
14/05/2013

30/09/2013
Insufficient capacity to Risk of poor patient experience and complaints arising from the There is an Outpatient Care Improvement 15 3 5 15 Implement Partial Booking for New Appointments Electronic grading of 31/10/2013 02/09/2013 3
meet demands in Central demand for outpatient clinics/activity having increased significantly Group that is aware of and progressing GP referral letters Improved use of Choose & Book System Reduce 29/11/2013
Booking Office over the past 4 years without the appropriate capacity match. The these matters Demand is usually Clinic Cancellations or Rescheduling DNA target met or exceeded Call 29/11/2013
main areas affected are appointment slot s & type, clinics & locations, managed through adhoc clinics, Handling to meet or exceed target Automate/Update DCW Clinic 27/09/2013
clinical environment e.g.seating, increasing adhoc clinics, staffing, overbooking of clinics. Bank, overtime Database Review of all OP Templates Create OP Operational Policy 30/08/2013
non pay, patient experience, inability to cosistently meet 18wk and TOIL is also used tro offset demand Realise costs incurred to OBO 31/10/2013
pathways and NHS Constitution A Transformation & Redesign 27/12/2013
Workstream has been established to 30/09/2013
review the activity demand and capacity 27/09/2013
requirements in CBO 28/03/2014
ICT Infrastructure
1462
27/06/2013

30/09/2013
Paediatrics

Archiving of echo Unable to connect the machine to a central storage facility, such as Images periodically archived to CD 15 3 5 15 IT solution being identified 30/12/2013 1
WCH

cardiology images PACS so that images are stored locally on the machine and archived
to CDs. This is a trust-wide problem, affecting the main cardiology
department as well.