Corporate Risk Register - Risks in risk score order WESTON AREA HEALTH NHS TRUST

MAY 2009
version 4 19/05/2009

Consequences
Likelihood

Risk Score
AF Ref Date on Description of Risk Key causes Domain or Source of risk Risk Control plan Completi Date of Op Lead Director Evidence Service Division Type
ref register underlying risk standard on date review Lead received of
the risk actions taken
challenges

corp125 Safeguarding Feedback from 5 5 25 Document local policy april 09 Jun-09 AND Dir
vulnerable adults - local authority draft merged job april 09 Nursing
Failure to meet description april 09
statutory service sisters + matrons to
delivery undertake training
requirements ED and EAU staff to june 09
undertake training april 09
determine methods for
ongoing tng april 09 patient safety
matron's lead role at all
strategy meetings april 09
clarification of process
lack of local policy for reporting
lack of training safeguarding issues june 09
lack of clarity equality impact
relating to reporting assessments on all
4 Apr-09 of concerns existing trust policies Board report 6/5
2 rad 56 May-09 Radiology general Insufficient 100% Risk Register; 5 4 20 Business case for extra Jun-09 MB / SS Dir of Business case Radiology Clinical Staffing
- Risk to service radiologist reporting of Incident + replacement Ops and notes of Support
delivery - provision establishment to radiation reports; Radiologist to TMC TMC
of timely reporting address workload, investigation IRMER; Adverts placed - joint
on films, scans reporting standards s IRMER; Assurance posts with Taunton
or subspeciality Safe framework; develop links with
interests provision of Risk UBHT/NBT consider
diagnostic Assessment.L double reporting from
results etter from Frenchay
consultants

2 Corp 128 May-09 Resuscitation - current systems in C1 and C7 report to CQG 5 4 20 Resuscitation committee Jun-09 IB Director Update to IGC
Failure to comply need of review and committee - revised and reconvened. Nursing committee
with audit updating review of Action plan developed monthly
regulations and current
2 emer 1 May-09 Junioril Doctors
id li - shortage of junior C11 C10 ti
medical 4 5 20 Introduce competency Jun-09 JO Medical Emergency Clinical quality
shortfall of junior doctors and quality directors report based interviews/clinical Director/
doctors to cover rota of locum doctors - recent competency exam for Dir Ops
removal of 2 locums
junior doctors

2 SLT 66 Risk to patient care Speech therapy Patient Care Risk 5 4 20 Proposal documented as Jan-09 Mar-09 Pauline Dir of Speech Clinical quality
/extended lengths of services on wards & Safety assessment part of stroke care Siddall Ops Language
hospital stay arising + rehab do not pathway Therapy
from dysphasgia currently meet
and communication stroke care
difficulties pathway standards

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 Consequences
Likelihood

Risk Score
AF Ref Date on Description of Risk Key causes Domain or Source of risk Risk Control plan Completi Date of Op Lead Director Evidence Service Division Type
ref register underlying risk standard on date review Lead received of
the risk actions taken
challenges

2 ele 133 12.3.09 Opthalmology - Lack of adequate SfBH Complaint + 5 4 20 Validation of existing March 09 Apr-09 KW D of Ops notes of SLA Opthalmology Elective Patient safety
Risk to continuance opthalmology staff Patient formal followup list meetings and service
of service access resources and Safety correspondenc Pending lists introduced March 09 waiting list delivery
failure to implement e from service for this service information for
appropriate lead Review underway re April 09 opthalmology
systems to ensure service provision
follow-up patients Will address through April 09
seen in a timely SLA process for 09/10
manner Additional lists to be put April 09
in place - funding
secured from D of F

2 rad 58 May-09 Breast radiology - Inability to fill Medical 5 4 20 partnership with another
delivery of the vacant posts Directors NHS Trust or consider
service report to Board early implementation of
digital mammography to
facilitate remote
2 Corp 127 Apr-09 Patients acquiring Poor assessment C7 6 incidents in 5 4 20 External review Jul-09 Tissue Director Report to CQG
pressures sores of patients at risk March -green requested - to be viability Nursing committee 14/5
whilst in hospital and clinical SUIs undertaken by DH lead nurse plus ward level
management lack profile raised via action reports
of robust systems goverance report
and processes for strengthen internal
tissue viability reporting - matrons
24hrs DON 48 hrs for all
HA pressure sores.
Referral to safeguarding
team for all non hospital
acquired pressure sores.

3 wac 51 Jan-07 Paediatric OT - risk OT staffing for Compromis

Complaints, 4 4 16 Address as part of Nov 2008 Apr-09 KR Dir of Occupational Clinical Staffing
of delayed children es all NSFs, overall OT and Physio Ops Therapy Support
improvements to inadequate.- standards
Children’s act review and develop a
and/or aggravation current 16 - 18 for and Every business case for IG May 09
of physical disability mnth waiting list children’s
child matters.
servicesRisk
assessment
3 ict 115 Nov-07 Information Lack of resource to Statutory Risk 4 4 16 Propose addition of PT Jul 2009 Apr-09 Head of Dir. N/A IT Finance & Compliance;
governance - manage and enact compliance; assessment IT Governance Manager SS&CS Finance IM&T Service
Breach of Information Service for FY 09/10 & IM&T delivery and
confidentiality, loss Security delivery; capacity
of patient, personal programme Patient
or trust data. safety;
Reputation;
Financial

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 Consequences
Likelihood

Risk Score
AF Ref Date on Description of Risk Key causes Domain or Source of risk Risk Control plan Completi Date of Op Lead Director Evidence Service Division Type
ref register underlying risk standard on date review Lead received of
the risk actions taken
challenges

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 corp May-09 medicines need to review NPSA incident 4 4 16 Action plan to be Jul-09 IB CM Notes of Drug
/eme 65 management - low policy and lack of reporting and developed by drug and and therapeutics
incident reporting of robust systems and divisional risk therapeutics committee committee,
errors and wide processes register incident reports
variation in reporting and reaudit
and failure to meet
3 ict 100 Nov-07 Information Lack of awareness Statutory Risk 4 4 16 Progressing: Jul 2009 Apr-09 Head of Dir. Over 1,000 staff IT Finance & Information;
governance - Risk of risks by staff; compliance; assessment Information security SS&CS Finance (perm and IM&T compliance
of breach of Lack of built-in Reputation; awarenes training; & IM&T external) trained;
confidentiality, loss protection against Financial and implementation of
of patient, personal use of portable McAfee Safe Boot
or trust data. devices alongside use of
hardware encrypted
memory sticks.
2 Corp 126 May-09 Falls - potential inconsistent risk patient number of 4 4 16 Falls prevention group Associate Dir report to CQG clinical quality
patient injury assessment and safety and incidents established and falls Director Nusing committee 14/5
preventative action service reported assessment tool Nursing
lack of robust delivery introduced
systems and
processes
1 ict 104 Nov-07 Litigation and Inadequate Statutory Risk 4 4 16 Service Management Apr 2010 Sep-09 Head of Dir. In SS&CS capital IT Finance & Compliance
financial penalties. software licence compliance; assessment system required to SS&CS Finance plan submission IM&T
management Reputation; support IT asset & IM&T
processes+D30 Financial management.

2 ict 110 Nov-07 patient systems - Lack of disaster Statutory Risk 4 4 16 Working paper Dec 2009 Jun-09 Head of Dir. Paper provided IT Finance & Service
Patient safety and recovery compliance; assessment produced. Infrastructure SS&CS Finance to A&A Cttee IM&T delivery and
hospital operations mechanisms in Service Manager to address. & IM&T capacity
compromised by place for IT delivery;
prolonged loss of systems in Patient
systems, diagnostic particular, safety;
in particular. diagnostic systems, Financial
hearing function
testing
3 ict Aug-06 Data quality - Weaknesses in the ALE KLOE Risk 5 3 15 Millenium improvement Jun-09 Head of Finance Report to Information Finance, Information
97/wac Failure to re-coup Cerner NCRS 5.1 assessment plan + data quality action Informatio Director Operational IM&T &
118 income for activity system i.e. data plans documented Ongoing n Management Performance
undertaken, failure quality, data Regular monitoring of Committee and
to plan or make completeness, progress against plan via statements of
appropriate and inaccurate ops group income recevied
timely decisions performance improve quality reporting
datadata recording and reconcile 2009/10
for child health data review of child
system health system realtive to
millenium
Consequences
Likelihood

Risk Score

AF Ref Date on Description of Risk Key causes Domain or Source of risk Risk Control plan Completi Date of Op Lead Director Evidence Service Division Type
ref register underlying risk standard on date review Lead received of
the risk actions taken
challenges

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2 ict 111 Nov-07 Patient safety and All external Statutory Risk 3 5 15 Dependent on Estates Ongoing Jun-09 Head of Dir. Raised with IT Finance & Service
hospital operations communications is compliance; assessment strategy. SS&CS Finance Inventures IM&T delivery and
compromised by routed through a Service & IM&T capacity
loss of systems and single trench. delivery;
all telephony. Patient
safety;
Financial

3 phys 62 Physiotherapy - Over-referral from Pt Complaints. 5 3 15 Business case for March On Neil Evett Dir of Physio Clinical Staffing
risk of reduced PCT resulting in experience Risk additional staffing 2009 going. Ops Support
quality of care, lack of sufficient assessment Agency member of staff
reduced patient staff resource Incidents agreed for interim April 09
experience, delayed resulting in appointment (I month)
recovery and insufficient follow- Discussions with PCT re Ongoing
increased length of up. block contracts +
stay on wards. referrals
Potential for claim
against Trust

3 wac 112 Mar-08 Drove Road site - Poor visibility on Health and 1 road traffic 3 5 15 Reviews, assessments July 08 Apr-09 KR Dir of Reports to H&S Community Children, staffing
risk of physical access to and Safety accident; and investigtions Ops Committee and child health & Young People
accident/injury egress from Drove statutory several near undertaken March 09 CQGC on issue; CAMHS & Maternity
arising from road Road Site + speed compliance misses Interim actions re. minutes of those
traffic collision of traffic through involving signage being meetings provide
site pedestrians undertaken; evidence; details
Unclear site and vehicles + Full capital solution of visit to site
boundary definition divisional risk identified + busines case and risk
register + risk being developed assessments,
assessment quotes for work
etc.

2 ele 109 Feb-09 Failure to sustain capacity mismatch National Divisional risk 3 5 15 Mtg with PCT to reduce March 09 Apr-09 KW Dir Ops MSK and oral Elective Service
delivery 13 week with demand guidance/ register waiting times for referral delivery and
RTT target by service into MSK clinic capacity
speciality delivery Resolve timeliness of March 09
MRI scanning
appointments May 09
Resolve ability to track
pts on RTT pathway March 09
Seek agreement for
merger of oral surgery +
head + neck

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 Consequences
Likelihood

Risk Score
AF Ref Date on Description of Risk Key causes Domain or Source of risk Risk Control plan Completi Date of Op Lead Director Evidence Service Division Type
ref register underlying risk standard on date review Lead received of
the risk actions taken
challenges

2 corp 124 Possible non- Insufficient staff to Pt Safety Risk 3 5 15 Blood transfusion Apr-09 Frank Director Minutes from Haematology Clinical Clinical quality
compliance Non deliver training HCC SbH assessment practitioner appointed Booth of Transfusion Support
compliance with Lack of training Training programme Nursing Committee and
the NPSA Safer programme developed HSGC meetings.
Practice Notice Proposed actions June
(SPN) 2006 ‘Right required to meet 2008
patient, Right Blood’, requirements detailed in
and of the Health paper presented to
Service Circular HSGC
‘Better Blood
Transfusion’ 2007.

3 estates Risk of fire/ safety Storage of furniture Patient care local risk 3 5 15 Identify more storage Aug-09 Jun-09 Clive Dir Ops Audit of corridors Estates support patient safety
breach and and linen in & Safety register appropriate storage Duran and ward areas
increased risk fo corridors and on SbH space for furniture and by estates
infection from wards which should linen manager
3 SLT 65 2008 Risk of inequitable No speech therapy Patient Care Risk 5 3 15 Expression of interest to Oct 08 Mar-09 Gillian Dir of Speech Clinical quality
and/or inadequate for hearing & Safety assessment PCT x2 Oxley Ops Language
patient care and impaired children in Negotiating with local Ongoing Therapy
consequent risk to Nth Somerset - not authority re. LD provision
reputation of funded by PCT
organisation Insufficient funding
for SLT services for
severe and
complex learning
disabilities

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