Agenda item

Oxford University Hospitals NHS Foundation Trust has been invited to present the Trust’s Annual Quality Account for this year.

The Committee is RECOMMENDED to:

a) AGREE to provide feedback on the Trust’s Quality Account.

b) AGREE to finalise the wording of the feedback subsequent to and outside this meeting, and to submit the feedback to the Trust prior to the publication date for the Quality Account at the end of June 2026.

PLEASE NOTE: There are TWO documents attached to this item:

1.    A Cover Letter submitted to the Committee by Oxford University Hospitals NHS Foundation Trust for this item.

2.    The full draft Oxford University Hospitals NHS Foundation Trust quality account.

Rustam Rea (Deputy Chief Medical Officer and Director of Clinical Improvement, Oxford University Hospitals NHS Foundation Trust); Olivia Clymer (Director of Strategy and Partnerships, Oxford University Hospitals NHS Foundation Trust), and Caroline Armitage (Deputy Head of Clinical Governance, Oxford University Hospitals NHS Foundation Trust) presented the OUH quality account for the year 2025-2026.

The Committee examined the Trust’s implementation of the Patient Safety Incident Response Framework (PSIRF). The Deputy Chief Medical Officer and Director of Clinical Improvement explained that the Trust had used the Health Services Safety Investigations Body (HSSIB) investigation quality tool to assess the quality of investigations before and after implementation of PSIRF and had found significant improvement across all nine assessed domains.

The Committee raised a specific issue relating to learning from deaths and referred to a prevention of future deaths report from August 2025, asking whether this had been incorporated into the Trust’s learning processes and how the Trust engaged with bereaved families where learning arose from a death. The Deputy Chief Medical Officer and Director of Clinical Improvement explained that both the Trust’s hospital standardised mortality ratio and summary hospital-level mortality indicator were within expected or better‑than‑expected ranges, and that the number of prevention of future deaths notices received by the Trust had reduced in recent years. He attributed this partly to improvements in the quality of investigations and the evidence the Trust was able to present to coroners in relation to learning and action taken. The Trust would need to look back at the specific case referenced by the Chair, but where a death revealed learning, the Trust initiated a formal learning response and engaged with relatives to understand their concerns and insights.

Members asked whether bereaved families were informed about how learning had been embedded and whether there was any offer of co‑production in such situations. Officers confirmed that the Trust actively involved families as part of its investigations into relevant deaths, used family liaison officers where appropriate, and sought to feed back on what had been learned and what had changed as a result.

The Committee asked why some quality priorities from the previous year had been carried forward and whether the factors that had prevented full delivery—such as workforce, digital or financial constraints—had now changed sufficiently to avoid repeated slippage. In response, the Deputy Chief Medical Officer and Director of Clinical Improvement explained that in a number of cases the original quality priority had broadened as the work developed. He gave the example of deterioration management, where the Trust had realised that its existing platform was not sufficiently robust and had therefore procured a new machine and new digital platform for recording and escalating deterioration. Similarly, medicines reconciliation had proved to be a much broader issue than originally anticipated, requiring improvement in interoperability between primary care, community services and hospital systems, and had now become part of a wider digital programme.

The Committee referred to examples in the report of digital innovation, including glucose monitoring work and ambient voice technology, and asked whether patient safety champions and co‑production were embedded in that digital programme. The Deputy Chief Medical Officer and Director of Clinical Improvement explained that ambient voice technology had emerged from clinical services’ desire for a more efficient and modern method of producing consultation notes and clinic letters. He described the concept as involving software listening to a consultation and then generating a letter or note which could then be checked and shared.

The Committee enquired as to what the Trust meant by the term co-production, observing that different organisations appeared to use it differently and that the Committee increasingly found itself hearing references to “co‑production”, “co‑design” and “engagement” as if they were interchangeable. Officers responded that co‑production began with understanding what patients and families wanted answered and what improvements they themselves wished to suggest, and that it was more appropriately understood as an ongoing process or active conversation rather than a single event. The Director of Strategy and Partnerships added that the Trust was keen to keep developing its confidence and examples of co‑production, both in relation to care pathways and in the development of the Quality Account itself, including through open meetings and public engagement activity.

Members also raised concerns about the operation and version control of RESPeCT forms, particularly in situations where different versions of a patient’s form existed at home and in hospital or where families were unclear whether changes to a patient’s wishes had been reflected everywhere. The Deputy Chief Medical Officer and Director of Clinical Improvement described this as going to the heart of the absence of a fully shared digital care record, both locally and nationally. The issue had been raised with the Trust’s Chief Digital Information Officer, and that the challenge was to preserve the strengths of the Trust’s current RESPeCT and treatment escalation process while making it more shareable and updateable across organisational boundaries.

The Committee explored the Quality Account’s work on health inequalities and learning disability provision, including the rollout of a reasonable adjustment flag and delivery of Oliver McGowan training. The Deputy Chief Medical Officer and Director of Clinical Improvement explained that one reason for bringing this as a quality priority the previous year had been to give greater visibility and coherence to a large body of work already happening across the Trust. A divisional nurse now led a monthly learning disability group, a number of services had compiled registers of patients with learning disabilities, and those patients were being identified and prioritised in advance of operations, diagnostics and other procedures so that reasonable adjustments—including different access arrangements, communication support, patient information materials and trusted people accompanying them—could be put in place before the patient arrived. This was an ongoing process rather than a completed programme.

The Committee enquired about national audits, noting that sections of the account referred to some audit participation rates and case ascertainment levels being below 100 per cent. The Deputy Chief Medical Officer and Director of Clinical Improvement confirmed that the Trust reviewed all national audit results, regardless of the extent of participation, and stated that a meeting he was due to chair later that day was in fact focused on national audit outcomes.

Members returned to the quality accounts section on the discharge safety checklist and asked about current compliance levels, the interventions that had demonstrably reduced delayed discharge and length of stay, and how safety was being maintained around medication changes and patient understanding on discharge. The Deputy Chief Medical Officer and Director of Clinical Improvement said that this remained an ongoing quality priority. One of the most significant improvements had been the introduction of board rounds, which enabled teams to review all patients every day, identify who was likely to go home in the next few days, ensure that medications were reconciled and prepared in advance, and improve communication of discharge changes both digitally to primary and community care and directly to patients themselves.

Finally, the Committee asked about maternity services, noting that despite the considerable work undertaken and the recent improvement in the maternity rating from “requires improvement” to “good”, the report still showed that maternity remained an area requiring further attention. The Deputy Chief Medical Officer and Director of Clinical Improvement said that the Committee would join the Trust in acknowledging the amount of work undertaken in maternity and the significance of the improved rating, which had also contributed to the Horton site being rated “good” overall. He explained that the next stage of work would focus not only on outcomes—where the Trust had seen some positive indicators—but particularly on patient experience, with a quality priority aimed at understanding and improving the experience of women and families in real time rather than only retrospectively.

The Committee:

a) AGREED to provide feedback on the Trust’s Quality Account.

b) AGREED to finalise the wording of the feedback subsequent to and outside the meeting, and to submit the feedback to the Trust prior to the publication date for the Quality Account at the end of June 2026.