The client
States of Jersey – Healthcare sector
Challenge
Serious Incident.
Elizabeth Rourke died during routine day surgery carried out by a locum gynaecologist at the Jersey General Hospital in October 2006. Mrs Rourke’s death, and the trial and subsequent acquittal of the locum doctor, generated considerable public debate and seriously undermined staff morale and public confidence in the hospital.
Scope
In March 2009 the States of Jersey commissioned Verita to conduct an investigation into Mrs Rourke’s death and to identify contributory factors in order that system-wide lessons could be learned.
Process
Verita’s systematic investigation looked beyond the obvious (the locum had admitted to making a mistake during the operation) to examine broader organisational issues. The investigative team carried out 66 formal interviews and analysed 1000s of pages of notes and records including police and trial transcripts.
It found major organisational weaknesses, in particular weak leadership, lack of clinical engagement that had lead to an underdeveloped culture of patient safety, and poor recruitment and induction processes for locum doctors.
The Verita team was led by managing director Ed Marsden.
Outcome
Jersey General Hospital accepted all 30 of Verita’s recommendations and used its report as a catalyst for developing a patient-safety culture shared by managers and clinicians. Early outcomes include the setting up of care quality groups and an integrated governance committee, and the introduction of policies and procedures for recruiting locum doctors. As a result, the percentage of consultants in clinical leadership roles increased from zero in 2009 to 33 per cent in 2012; and all locum doctors are now interviewed before being employed and have job descriptions setting out the levels of skills and competencies required for their role.