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Professor Aitkenhead's reports on clinical governance at Jersey General Hospital

24 April 2012

Following the consent of the States Employment Board under Article 20(2) of the Health and Safety at Work (Jersey) Law, 1989, (HSW Law), the reports prepared by Professor Aitkenhead on the management of clinical governance at the General Hospital are being published by the Health and Safety Inspectorate.  Two names have been removed from the report.  In accordance with the Data Protection (Jersey) Law, 2005, the name of a patient has been removed from the initial report, and in response to a request from the Law Officers’ Department, the name of the person who provided them with legal advice who is referred to in the initial report has also been removed.  Apart from these amendments, the reports are published in full.


Professor Aitkenhead was commissioned by the Health and Safety Inspectorate to carry out a review of the management of clinical governance at the General Hospital following the investigation into the death of a patient, Mr Joseph Vasse, which occurred at the General Hospital on the 12th December 2008.  The investigation, which was carried out in conjunction with the States of Jersey Police, raised a number of issues which identified the need for a comparison to be made between arrangements for the management of clinical governance at the General Hospital and those in place in NHS Trusts in the United Kingdom.

Professor Aitkenhead first visited Jersey on the 4th and 5th May 2011, following which he produced his initial report dated 21st July 2011.  The Professor returned to the Island on the 14th December 2011 to review progress on the matters identified as a result of his initial visit, and subsequently produced a supplementary report, dated 29th March 2012.  Both reports were issued to Health and Social Services with whom the Inspectorate has continued to discuss the matters raised in the reports.

Initial report prepared by Professor Aitkenhead (size 769kb)

Supplementary report prepared by Professor Aitkenhead (208kb)

Legal duty placed on the States Employment Board

The HSW Law applies to all employers in Jersey including the States Employment Board.  

Article 5 of the HSW Law means employers must carry out their work in a way that ensures, so far as is reasonably practicable, the health and safety of those not in their employment.   As the employer of surgeons and medical practitioners who work at the General Hospital, this duty is placed on the States Employment Board (SEB), (through the Employment of States of Jersey Employees (Jersey) Law, 2005). 

Whilst SEB has delegated the responsibilities under this Law, (particularly, Article 5 of the HSW Law), to Chief Officers of States Departments, the legal responsibility to comply with the HSW Law, remains with SEB.

The Health and Safety Inspectorate is the regulatory authority with responsibility for enforcing the HSW Law. It must enforce the Law in accordance with a policy agreed by the Attorney General, which says enforcement must be consistent whether the Inspectorate is dealing with employers in the private sector or States Departments. 

Further information can be found in the Inspectorate’s enforcement policy.

Enforcement policy statement

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