Patient safety in Northern Ireland must remain priority, says Health Minister as review of deceased neurology patient records concludes

Health Minister Robbie Butler has responded to the Regulation and Quality Improvement Authority (RQIA)'s Final Report on the Expert Review of Records of Deceased Patients of Michael Watt.

Minister Butler thanked the families who have engaged in the Deceased Patient Review process for their invaluable contribution. 

The Minister said: I want to acknowledge the loved ones whose lives are being remembered today. Their loss is deeply felt by their families, and it is right that we pause to remember them and the impact their deaths have had on those closest to them.

I also recognise the courage and determination of the families who took part in the Deceased Patient Review. Their contribution has been central to ensuring that concerns were examined independently and that lessons can be learned to improve care for future patients and families.

The Minister acknowledges the report's findings are concerning. He said: Patient safety must always remain our fundamental priority. The findings in this report are deeply concerning and reinforce issues identified through an earlier phase of the review. I recognise the distress that this publication may cause, and on behalf of the wider Health and Social Care system (HSC), I sincerely apologise for the failings in care that have been identified.

This report provides an important opportunity to reflect on past failings and to strengthen patient safety across the HSC system. The findings reinforce the importance of openness, effective communication, multidisciplinary working, professional challenge and a culture in which concerns are listened to and acted upon. 

My Department remains committed to supporting initiatives that enhance patient safety, strengthen public confidence and help prevent similar failings from occurring in the future.

I want to thank the RQIA, Royal College of Physicians' review team and all those who supported families throughout the review process for their extensive work in this area.

In response to an earlier phase of the review, RQIA committed to ensuring that learning would be shared across the HSC. One significant outcome of that work has been the development of the Being Human framework , which seeks to strengthen a culture of safety, openness and learning across HSC. This complements the extensive programme of work the Department is taking forward to improve patient safety and quality through improving Governance, Culture, and Processes.

The publication of this report marks the completion of the expert review of deceased patients' records. The Department and RQIA will now consider the lessons arising from the review and how they can be implemented. 

Notes to editors:

1. The Final Report will be available here from 00.01 Thurs 10th Sept: https://www.rqia.org.uk/reviews/deceased-patients-review/(external link opens in a new window / tab)
2. In May 2018, the Department asked the RQIA to commission an Expert Review of the clinical case notes of the patients of Dr Michael Watt who died in the 10 years prior to the neurology recall (i.e. the Deceased Patients Review).
3. Phase One, which was a preparatory phase, concluded in November 2020 with the formal adoption of a Legal Framework to ensure access to the relevant records.
4. Phase Two pertains to the expert review of clinical records (involving 45 patient records) comprising: 29 deceased patients whose family members have approached the RQIA with concerns; and 16 patients who were included in the Belfast Trust's Cohort 1 neurology recall but unfortunately died before either attending or completing their re-assessment.
5. Phase Three pertains to the expert review of clinical records (involving 25 patient records) comprising: 18 deceased patients whose family members approached the RQIA with concerns raised by the patients' relatives about the care provided, and 7 deceased patients, whose family members approached RQIA with concerns following the WMS dated 3 July 2024 and made contact prior to 31 December 2024. The publication of Phase Three marks the conclusion of the expert review of deceased patients' records.  Consideration will now be given to the next steps arising from the review, including lessons learned and their application across the Health and Social Care system.
6. The Independent Neurology Inquiry (INI) Report was published on 21 June 2022 and includes a total of 76 recommendations.  It is very clear from the recommendations that patient safety is the paramount principle.  The Department of Health has established a governance structure, the INI Implementation Programme, to oversee the implementation of the INI Report recommendations.  The Programme Board, chaired by Permanent Secretary, convened for the first time on 6 October 2022.  To date 57 of the 76 recommendations have been implemented with work ongoing on the remaining 19 recommendations.