The Welsh Risk Pool plays a key role in assuring that learning is undertaken and implemented following complaints or incidents which result in a redress, personal injury or clinical negligence claim. Sharing the learning across NHS Wales, is a key aim of the Learning from Events Programme.
A clinically led and multi-professional Learning Advisory Panel (LAP) was established over 5 years ago, as a recognised subcommittee of the Welsh Risk Pool Committee (WRPC). Chaired by established leaders from the Putting Things Right sector, the Panel meets monthly to scrutinise Learning from Events Reports (LFER), which highlight the learning implemented by health bodies, following a redress or clinical negligence case. During 2023-24, the Panel reviewed 618 new cases.
Doctor, midwife and nursing representatives participate in the LAPs, together with colleagues from governance and legal teams. Medical officers from Welsh Government contribute to each LAP. Multiple clinical specialities are represented, which ensures a widespread sharing of the learning.
A separate LAP has recently been established to review the learning implemented following a personal injury claim. This Panel is fully supported by Health and Safety professionals from across Wales and is already proving to be very successful.
The role of each LAP is to establish whether the learning implemented following each case, provides assurance that a similar incident is less likely to happen again in the future. If the Panel is assured, it recommends that the LFER is approved. If it is not assured, feedback will be provided and approval of the LFER will be deferred until the feedback is addressed. All LAP decisions must be reviewed, approved and ratified by the WRPC. Health bodies will only be reimbursed by the WRP for monies paid in relation to a claim (damages/costs etc), if the LFER has been approved.
The LAP plays a key role in identifying learning themes across Wales. The new WRP VTE Wales Programme to develop an All-Wales approach for the prevention and reduction of harm associated with venous thromboembolism (VTE), arose as a result of the LAP identifying increased VTE case numbers presenting to them.
Themes, trends and cases of interest are also shared in the quarterly newsletter, Doctrina. This has been well received by clinical leaders and disseminated within teams for wider learning.
The WRP Safety and Learning Team have exciting future plans to develop a new Learning from Events Hub. The Hub is a point of reference for the Learning from Events Programme, including data on themes, trends and specialities, cases of note and LFER training guidance and help. Access to the hub will be widened in 2024/25.
The Welsh Risk Pool Reimbursement Procedures provide a structured series of standards by which members of the risk pooling scheme should work. Guidance on each step of the process of Learning from Events and Submission for Reimbursement are best achieved; aiming to reduce the potential for the circumstances which led to a claim occurring from being repeated.