Verita Investigation - Clarification of Terms of Reference
The Minister for Health and Social Services has considered in consultation with her Assistant Ministers and independently from the Health and Social Services Department the terms of reference for the independent investigation into the care, treatment and management of Elizabeth Rourke. Mrs Rourke died tragically in hospital in October 2006.
The Minister believed that there was a need to clarify the terms of reference which had led to a great deal of confusion and misconception. She has also decided that the independence of the inquiry be further demonstrated and has instructed that contact with Verita should initially take place through the Chief Minister’s Department and subsequently the Greffe.
The terms of reference have been clarified and strengthened by:
- Making it fundamentally clear that Verita are investigating the details of what happened and the actions of individuals;
- Making it clear that the investigation will also be considering hospital and HSSD procedures and practices;
- Strengthening the report procedure and editorial control of the report;
- Requesting that an addendum be added to include matters that might be outside the terms of reference but about which the Minister should be aware, and
- Requesting Verita to revisit six months following the publication of the report to give a written report on progress with implementation.
A copy of the letter and the terms of reference are attached.
Tom Gales
Social Policy Adviser
Chief Minister’s Department
29 June 2009
Letter of clarification to Verita
Ed Marsden
Managing Director
Verita
53 Frith Street
London
W1D 4SN
26 June 2009
Dear Mr. Marsden
Independent investigation into the care, treatment and management of Elizabeth Rourke
Thank you for your presentation to States members on Wednesday afternoon. I am sure they found it helpful to meet the investigative team and to hear about progress with the work. As I said at the meeting, I am writing in my capacity as the new Health Minister in order to expand on and set out my expectations about the terms of reference and the handling of the independent investigation at the point that the report is ready for delivery. We have already discussed these points and I know that they coincide with your own thinking.
Terms of reference
My predecessor set your terms of reference and I am content to endorse them as I believe they focus on the right matters. However in the commissioner preamble before the terms of reference the second sentence reads as follows:
‘The investigation has no disciplinary remit and will not consider the acts and omissions of individuals.’
You have already said that the investigation team is looking in detail at the events of the day including who did what. As I understand it, the team is looking at these events in the context of hospital systems and procedures and patient safety and will be providing the fullest account possible of who did - or didn't - do what, and why, as is judged appropriate by you. I endorse this approach. I can also re-confirm that we are not asking you to carry out an investigation for the purposes of disciplining individuals. However any issues arising from the report will be dealt with under the relevant policies and procedures.
With respect to the first limb of your terms of reference I would be grateful if you would also include consideration of hospital and HSSD procedures and practices where the investigation team thinks this to be appropriate.
Submission of draft report and final report
I would be grateful if you would submit your draft report to me, the Greffier, the Deputy Viscount and the Chair of the Health, Social Security and Housing Scrutiny Panel once it is complete. The report will not be sent to the HSSD management team without the explicit, written agreement of me or the Greffier. If you propose to send the draft by electronic means then please ensure that the report comes to our own email addresses and is password protected. The password should be sent to us by means of a separate message.
I expect Verita to retain full editorial control of the draft report while it is fact-checked by HSSD and, if necessary, individuals comment about criticisms made of them. This will ensure that the contents of the final report are the considered views of the investigation team.
Publication and presentation
I re-confirm that I propose to publish your investigation report. I would like to do this in such a manner that your findings and conclusions are widely available. I would also like you and the team to present the findings of the investigation to States members and, separately, to the HSSD management team and staff. This is in addition to any press conference that we may hold.
Addendum to your report
At your discretion I would like you to prepare an addendum to your report. This should include matters that come to light during your work that are outside your terms of reference but the investigation team think we should know about. Should you feel the need to prepare such a document then it should be submitted to the same four individuals as set out above.
Follow-up
I am determined that the investigation report should not sit on the shelf. I will expect the HSSD management team to draw up an action plan in response to your recommendations. I will expect them to explain how the actions will be implemented and monitored. I will want to know who is responsible for each action and the timescale for completion. I want your team to revisit the hospital six months after the publication to check on progress and to submit a written account of your visit to me, the Greffier, the Deputy Viscount and the chair of the scrutiny panel. Based on the findings, I may wish for you to make a further visit to report on progress in the hospital.
Tom Gales, Social Policy Adviser, Chief Minister’s Department will, for the time being, act as your liaison officer. Day-to-day matters should be referred to him at the moment. I will further clarify Mr. Gales’ role and that of the Greffier’s office next week. In any event I would encourage you to keep Tom Gales and the Greffier posted if matters of concern arise during the investigation. I know that you are already doing this and I am grateful for that. Please also let us know if any witnesses who are employees of HSSD are reluctant to attend for interview.
I look forward to hearing from you. Meanwhile, I am copying this letter for information to the Greffier, the Deputy Viscount, the Chair of the scrutiny panel and Mr. Gales.
Yours sincerely
Deputy Anne Pryke
Minister of Health and Social Services
Terms of Reference for the Independent Investigation into the care, treatment and management of Elizabeth Rourke
Commissioner
The Minister of Health and Social Services, States of Jersey, has commissioned this independent investigation as part of his general obligations to ensure the safety of health services and improve the quality of care for patients. The investigation has no disciplinary remit and will not consider the acts and omissions of individuals. Rather it will provide a narrative explanation of the incident and consider organisational systems and processes.
Terms of reference
The purpose of the independent investigation is given below.
• Examine the care, treatment and management of Mrs. Elizabeth Rourke from her related GP referral up until the start of the police investigation.
• Review the main actions taken by the health and social services department in response to the death of Mrs. Elizabeth Rourke including its own interim internal investigation. This will include establishing whether or not there are any significant omissions to the investigation and, if so, exploring these.
• Review progress made against the recommendations of the interim internal investigation.
• Identify any further actions that the Health and Social Services department should take to improve the safety and quality of health services.
• Provide a written report with recommendations to the Minister.
Approach
The investigation team will carry out its work by reviewing relevant documentation and, where the team considers it necessary, interviewing key staff in private to enable people to speak freely. The team will follow established good practice in the conduct of the work e.g. by offering interviewees the opportunity to be accompanied and to comment on the transcripts of their interview.
The team will take account of the views of Mr. Rourke and Mrs. Rourke’s family in the conduct of their work.
Where appropriate the team will share information with those conducting other related investigations. They will report immediately any significant concerns to the Health and Social Services Minister.
Investigation team
The investigation will be carried out by Dr. Sally Adams, Derek Mechen and Ed Marsden supported by relevant expert advisers.
Timetable
The investigation team will aim to complete their work by September 2009.
Publication
The Minister will publish the outcome of the investigation and any recommendations that may arise.
Senator James Perchard
Minister of Health and Social Services
13th March 2009
gov.je