| Reference Number |
File Size |
Document Title |
Date |
| 401-001 |
2.4MB |
Letter from the Inquiry to DLS enclosing additional information request |
22-Jun-2016 |
| 401-001a |
1.2MB |
Email from DLS enclosing Health and Social Care Board's response to BC-0026-16 |
30-Aug-2016 |
| 401-001b |
675KB |
Appendix 1 - Agenda for Learning Event |
01-Jun-2016 |
| 401-001c |
1.6MB |
Appendix 2 - Learning Output from HSC Complaints Learning Event - Learning from Complaints |
01-Jun-2015 |
| 401-001d |
798KB |
Appendix 3 - Communication to Service Users Families and Carers following receipt of an SAI |
01-Jan-2015 |
| 401-001e |
865KB |
Appendix 4 - Annual-Complaints-Report-2014-1015 |
Apr-16 |
| 401-001f |
492KB |
Appendix 5 - Paper describing the communication pathways between Coroners' Office PHA and HSCB |
01-Dec-2014 |
| 401-001g |
621KB |
Appendix 6 - Letter to Coroner's Office |
16-Apr-2015 |
| 401-001h |
635KB |
Appendix 7 - Response from Coroner’s Office |
19-Jun-2015 |
| 401-001i |
602KB |
Appendix 8 - Letter to Elaine Way |
14-Jul-2015 |
| 401-001j |
589KB |
Appendix 9 - Letter to Hugh McCaughey 14 July 2015 |
14-Jul-2015 |
| 401-001k |
589KB |
Appendix 10 - Letter to Michael McBride 14 July 2015 |
14-Jul-2015 |
| 401-001l |
603KB |
Appendix 11 - Letter to Paula Clarke 14 July 2015 |
14-Jul-2015 |
| 401-001m |
586KB |
Appendix 12 - Letter to Tony Stevens 14 July 2015 |
14-Jul-2015 |
| 401-001n |
1.2MB |
Appendix 13 - Learning Report Serious Adverse Incidents |
Mar-16 |
| 401-001o |
884KB |
Appendix 14 - DHSSPS Process for reporting Child Deaths - issued to all HSC Organisations |
13-Jan-2016 |
| 401-001p |
547KB |
Appendix 15 - Letter and Revised SAI Criteria issued to all DOH Arm's Length Bodies |
13-Jan-2016 |
| 401-001q |
514KB |
Appendix 16 - Correspondence from Director of Commissioning to HSC Trusts July 2015 |
14-Jul-2015 |
| 401-001r |
521KB |
Appendix 17 - Update paper to SQAT 10 November 2014 |
10-Nov-2014 |
| 401-001s |
566KB |
Appendix 18 - Reg Paed EWS under 1yr 2015 |
|
| 401-001t |
520KB |
Appendix 19 - Reg Paed EWS 1-5 2015 |
|
| 401-001u |
571KB |
Appendix 20 - Reg Paed EWS 6-12 2015 |
|
| 401-001v |
574KB |
Appendix 21 - Reg Paed EWS 13-16 2015 |
|
| 401-001w |
880KB |
Email from DLS enclosing Belfast Health and Social Care Trust's response to BC-0026-16 |
|
| 401-001x |
2.4MB |
Policy and Procedure for the Management of Complaints and Compliments. |
01-Sep-2013 |
| 401-001y |
613KB |
Specialist Hospitals & Women’s Health Complaints Flowchart |
01-Jun-2016 |
| 401-001z |
2.1MB |
BHSCT - You have made a complaint - What Happens Next? |
|
| 401-001aa |
635KB |
What do I need to know about Serious Adverse Incidents (SAI) |
|
| 401-001ab |
1.3MB |
Serious Adverse Incident (SAI) Procedure |
01-Aug-2016 |
| 401-001ac |
1.7MB |
Serious Adverse Incident (SAI) Procedure |
09-Jul-14 |
| 401-001ad |
2MB |
‘Being Open’ policy – saying sorry when things go wrong. |
06-Feb-15 |
| 401-001ae |
574KB |
Safety Message of the Week |
|
| 401-001af |
2.2MB |
Safety Matters |
01-May-2016 |
| 401-001ag |
1.7MB |
Safety & Quality Leadership Walkround – Proposal for 2016/17 |
|
| 401-001ah |
475KB |
Coroner's Witness Statement - Blank |
|
| 401-001ai |
872KB |
Medsafe |
01-Mar-2015 |
| 401-001aj |
544KB |
SAI - Shared Learning - Item 5.1.1 |
14-Sep-2014 |
| 401-001ak |
482KB |
SAI - Shared Learning - Item 5.1.2 |
29-Oct-2013 |
| 401-001al |
521KB |
SAI - Shared Learning - Item 5.3.1 |
12-Jun-2015 |
| 401-001am |
1.3MB |
A Review of SAIs relating to the ‘Misidentification of Patients |
01-Jun-2015 |
| 401-001an |
1.5MB |
Policy for recording fluid prescription and balance charts V5 |
01-Feb-2015 |
| 401-001ao |
5MB |
Paediatric IV Fluid Audit Improvement Tool |
07-Mar-2016 |
| 401-001ap |
686KB |
FBC Audit breakdown |
Jun-16 |
| 401-001aq |
701KB |
Paediatric IV Fluid Audit Improvement Tool (PIVFAIT) Audit Tool |
|
| 401-001ar |
591KB |
Paediatric FP&B chart - Overall monthly hospital compliance result sheet |
|
| 401-001as |
536KB |
Shared Learning - Item 5.1.3 - Safety Message: The Falls Risk Assessment must be completed on all inpatients identified as at risk of falling |
01-Jun-2016 |
| 401-001at |
846KB |
Policy for sharing learning V2 - Ref No TP 98/14 |
01-Apr-2016 |
| 401-001au |
1.5MB |
Procedure for the Reporting and Follow up of Serious Adverse Incidents |
01-Oct-2013 |
| 401-001av |
884KB |
PROCESS FOR REPORTING CHILD DEATHS |
|
| 401-001aw |
1.1MB |
BOARD ASSURANCE FRAMEWORK |
|
| 401-002 |
2MB |
Letter from the Inquiry to DSO enclosing additional information request |
22-Jun-2016 |
| 401-002a |
750KB |
Letter from Brian Godfrey, DOH re BC-0227-16 |
05-Jul-2016 |
| 401-002b |
2.7MB |
Letter from DSO enclosing response to BC-0227-16 |
19-Jul-2016 |
| 401-002c |
2.7MB |
Circular Reference HSC(F) 08-2016 - Response to PAC recommendation on the use of Confidentiality Agreements |
14-Jan-2016 |
| 401-002d |
74KB |
Letter from John Leckey, Senior Coroner for Northern Ireland to John Compton CE, HSCB |
02-Apr-2014 |
| 401-002e |
607KB |
Letter from Michael McBride, CMO to John Leckey, Senior coroner for Northern Ireland |
18-Apr-2014 |
| 401-002f |
184KB |
Letter from Michael McBride, CMO to Chief Executives of HSC Trusts, Medical Directors of HSC Trusts |
18-Apr-2014 |
| 401-002g |
711KB |
Letter from Jim Wells, Minister for DHSSPS to Alastair Ross, MLA |
25-Feb-2016 |
| 401-002h |
2.3MB |
Regional Mortality and Morbidity Review System Project - User Requirements Specification |
17-Feb-2016 |
| 401-002i |
1.1MB |
Public Health Agency - Central Repository for HSC resources relating to Hyponatraemia |
25-Feb-2016 |
| 401-002j |
1MB |
NIPEC Quality Assurance Framework for DHSSPS Commissioned Practice Development and Education Programmes (Non NMC Registered or Recorded) Non-NMC Monitoring. Provider QUB; course - Nursing Care of the Critically Ill Child |
02-Jul-2013 |
| 401-002k |
915KB |
NIPEC Non NMC QA Monitoring Progress Report 2013-2014. QUB for: Nursing Care of the Critically Ill Child. |
26-Jun-2014 |
| 401-002l |
968KB |
NIPEC Quality Assurance Framework for DHSSPS Commissioned Practice Development and Education Programmes (Non NMC Registered or Recorded) Non-NMC Monitoring. Provider CEC; course - Fluid Management in Children and Young People (from 1 month to age up to 16 years only) |
21-May-2014 |
| 401-002m |
968KB |
NIPEC Non NMC QA Monitoring Progress Report 2014-2015. Provider CEC; course - Fluid management in Children and Young People (from 1 month to age up to 16 years only). |
11-Jun-2015 |
| 401-002n |
968KB |
NIPEC - Activity and Outcomes for Recording Care 2009 - 2016 |
|
| 401-002o |
706KB |
Policy Circular - Establishing an early Alert System - HSC (SQSD) 10/2010 |
01-May-2010 |
| 401-002p |
1.2MB |
Procedure for the Reporting and Follow up of Serious Adverse Incidents |
01-Oct-2013 |
| 401-002q |
1.1MB |
Letter from Inquiry to DSO re clarification to answers provided in letter dated 19-07-16 |
16-Aug-2016 |
| 401-002r |
1.5MB |
Letter from DHSSPS to Inquiry enclosing response to letter dated 16th August 2016 |
24-Aug-2016 |
| 401-002s |
895KB |
Letter from DHSSPS to HSC Organisations |
13-Jan-2016 |
| 401-002t |
798KB |
A Guide for Health and Social Care Staff. Engagement/Communication with the Service User/Family/Carers following a Serious Adverse Incident |
01-Jan-2015 |
| 401-002u |
1.2MB |
Learning Report - Serious Adverse Incidents - April – September 2015 |
01-Nov-2015 |
| 401-002v |
1.2MB |
Learning Report - Serious Adverse Incidents - October 2015 – March 2016 |
01-Jun-2016 |
| 401-002w |
1.4MB |
Regional Learning System Project Report |
01-May-2015 |
| 401-003 |
1.2MB |
Letter from the Inquiry to Olive Macleod, RQIA enclosing additional information request |
22-Jun-2016 |
| 401-003a |
466KB |
Letter from Olive Macleod, RQIA to Inquiry enclosing response to letter dated 22 June 2016 |
22-Jul-2016 |
| 401-003b |
1.5MB |
RQIA Schedule of responses |
|
| 401-003c |
844KB |
Action Plan to implement the Recommendations outlined in the ‘Complaints in the HSC Evaluation Report’ |
|
| 401-003d |
1.7MB |
RQIA - Three Year Review Programme | 2015-18 |
|
| 401-003e |
1.3MB |
Quality Assurance of the Review of the handling of all Serious Adverse Incidents reported between 1 January 2009 and 31 December 2013 |
01-Dec-2014 |
| 401-003f |
2MB |
Letter from Valerie Watts, CE HSCB and Eddie Rooney, PHA to Chief Executives HSC, ALB's and Special Agencies enclosing A Guide for Health and Social Care Staff. Engagement/Communication with the Service User/Family/Carers following a Serious Adverse Incident |
11-Feb-2015 |
| 401-003g |
2MB |
Procedure for the reporting and follow up of Serious Adverse Incidents |
01-Oct-2015 |
| 401-003h |
655KB |
Letter from Inquiry to RQIA re clarification to answers provided in letter dated 22-07-16 |
16-Aug-2016 |
| 401-003i |
944kb |
Letter from RQIA in response to letter from Inquiry dated 16th August 2016 |
13-Sept-2016 |
| 401-003j |
563KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
19-Dec-2013 |
| 401-003k |
563KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
15-Apr-2014 |
| 401-003l |
1.4MB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
17-Jun-2014 |
| 401-003m |
1.4MB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
03-Sep-2014 |
| 401-003n |
1.3MB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
09-Dec-2014 |
| 401-003o |
897KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
17-Dec-2014 |
| 401-003p |
896KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
13-May-2015 |
| 401-003q |
896KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
11-Aug-2015 |
| 401-003r |
887KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
04-Nov-2015 |
| 401-003s |
889KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
13-Jan-2016 |
| 401-003t |
880KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
09-Mar-2016 |
| 401-003u |
880KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
11-Mar-2016 |
| 401-003v |
886KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
05-Jul-2016 |
| 401-003w |
886KB |
DHSSPS/RQIA Bi Monthly Liaison Meeting - Agenda |
14-Sep-2016 |
| 401-003x |
1.1MB |
Review of the Operation of Health and Social Care Whistleblowing Arrangements |
Sep-2016 |
| 401-004 |
1MB |
Letter from the Inquiry to the Honourable Mr Justice Colton requesting information |
22-Jun-2016 |
| 401-004a |
2.7MB |
Letter from Coroners Service re BC-0227-16 enc response to Questions 9 and 12 of DOH Schedule |
22-jun-Sept-2016 |
| 401-005 |
748KB |
Letter from the Inquiry Maeve Hully, Patient Client Council, re Donaldson report |
24-Jun-2016 |
| 401-005a |
1.3MB |
Email from PPC in response to BC-0229-16 |
26-Jul-2016 |
| 401-005b |
662KB |
PCC response document to The Donaldson Report Recommendations - Consultation Response Questionnaire |
Feb-2016 |
| 401-005c |
985KB |
PCC report on the public responses were received |
May-2016 |
| 401-005d |
815KB |
Letter to the DOH Minister with the PCC Board response to Donaldson |
13-Apr-2015 |
| 401-005e |
523KB |
Email from Inquiry to Maeve Hully, PCC with further questions |
02-Aug-2016 |
| 401-005f |
1.1MB |
Email from PCC in response to Inquiry email dated 2nd August 2016 |
17-Aug-2016 |
| 401-006 |
1.6MB |
Email from Inquiry to GMC re GMC referrals from Northern |
22-Jun-2016 |
| 401-006a |
1.6MB |
Letter from GMC to Inquiry updating information requested |
21-jul-2016 |
| 401-007 |
1MB |
Email from Inquiry to NMC re updating information on referrals to NMC from Northern Ireland |
22-Aug-2016 |
| 401-007a |
948KB |
Email from NMC in response to Inquiry email dated 22nd August 2016 |
09-Sept-2016 |
