Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Belfast Health and Social Care Trust Jennifer Welsh, the chief executive; Professor Stuart Elborn, the chair; Chris Hagan, medical director; Olga O'Neill, executive director of nursing and user experience; and Dr Peter Sloan, interim director of mental health and intellectual disabilities. You are all very welcome. Apologies for the delay in calling you in.

I refer members to the papers in our pack. An email was sent round this morning from Glynn Brown from Action for Muckamore, with a link to some documentation that he wanted to make us aware of.

I will hand over to you now. We will probably allow an hour or an hour and 10 minutes, Jennifer, if that is OK.

Ms Jennifer Welsh (Belfast Health and Social Care Trust): Yes, absolutely. Chair, thank you very much. Good morning to you and members of the Committee. Thank you for your invitation to be here today. You have introduced my colleagues. No one with me today feels anything other than deep shame, sorrow and anger about what happened at Muckamore Abbey Hospital, and, on behalf of my colleagues, I want to restate my profound and unreserved apology to the people who lived at Muckamore Abbey Hospital and who experienced abuse, neglect and, at times, cruelty. I am deeply sorry for everything that they suffered and for the lasting impact that such appalling behaviour will have left on them. To the families whose child or sibling experienced abuse, neglect or cruelty, to those who fear that that has happened to their loved one and to families whose child or sibling was impacted on and has since died, I would like to restate and extend a full and heartfelt apology for the profound impact that that has had on them, on their loved one and on their wider family. As current chief executive and chair, Stuart and I take full responsibility for the wrongs that were committed.

The abuse and, at times, the neglect are shocking in themselves, but that they happened at the hands of caregivers is a dark chapter in the history of caring for people with learning disabilities and autism on these islands. While those staff who perpetrated such incidents should rightly take the blame and face the consequences, the core of the report goes much deeper and further, illuminating a rot that permeated deep into a culture and a way of life at Muckamore that were systemic. Evidence to the panel and testimonies from families and expert witnesses have, in highlighting the systemic failures at Muckamore Abbey Hospital, thrown down a gauntlet to the wider health and social care (HSC) system when it comes to how we provide lifelong, holistic care in partnership with families, in collaboration with the community and voluntary sector and, most importantly, with the needs and the opinions of people with learning disabilities and autism front and centre. At the core needs to be a certainty that people with learning disabilities are worthy of an equal and full life and that they should have as much of a stake in their future as I have in mine. Therefore, if we see Muckamore Abbey Hospital as a microcosm of the health and social care system, we agree that the recommendations are an action plan.

I know that families want to see results. All of us here today are on the same page, and now is when the rubber hits the road. Let me assure members that each of us here today is steadfast in our commitment to get this right, and I say that also on behalf of the staff whom we represent. Listening is the first thing that we want to get right. Stuart and I have written to families to apologise to them and with the offer of individual or group meetings for those who would like to meet. I am pleased to say that we have begun that journey. I know that Stuart will agree with me when I say that, while those meetings are difficult, the grace and the composure of the loved ones whom we have met and the frank discussions that we have had have left us cautiously optimistic that, in time, we can, hopefully, go forward together. One of the things that has struck me, particularly from communication with families, is their keenness, in spite of everything, to work with us as we go forward in designing services on the ground and in strategic thinking about the future model of care and the part that we can play collaboratively with all parties in getting this right.

In healthcare, we talk in general terms about the status of the expert patient, meaning that the service user, or their family, knows their needs better than anyone. I have been struck so deeply by the expertise of those families, who know their loved one in a granular way that no healthcare system could possibly replicate. I ask with no small degree of regret and frustration why on earth they were not listened to. What elevated our expertise over theirs? In the report, Tom Kark states:

That does not mean that we will always agree or that the expert healthcare opinion should be ignored, but, in the case of Muckamore, the trust clearly enabled the existence of a controlling and paternalistic environment that could not be challenged.

I will turn to a serious concern raised in the inquiry report: the trust's perceived adversarial approach to the inquiry. It is fair to say that those comments were unexpected and sobering and that they absolutely stopped us in our tracks. The Belfast Trust did not set out to be adversarial, oppositional or confrontational, although we acknowledge that, at times, there were difficult communications with the inquiry. However, we endeavoured to support the work of the inquiry and to cooperate with it at all times, complying with all the inquiry's notices and requests for information. For example, we provided over 425,000 pages of material to the inquiry, including detailed statements addressing wide-ranging topics. In total, the inquiry received over 45,000 pages of witness statements and accompanying exhibits from the trust. There is no doubt, however, that, as the inquiry went on, correspondence with it on some issues became increasingly difficult. Again, I do not believe that there was ever any intention to be adversarial or confrontational, and I take heart from Tom Kark's comment that, in spite of a perceived adversarial approach:

Whilst there were difficult communications with the inquiry at times, I was told, when speaking with our legal team, that they did not at any time throughout the inquiry have a single cross word with the representatives of the families and that they enjoyed a collaborative and supportive working relationship that endured throughout the lifespan of the inquiry. Knowing the toll that it took for staff to attend the inquiry and the dedication and commitment that were required of a small team of trust staff to provide the hundreds of thousands of pages of evidence over several years, I can say that the fact that the trust was perceived as being obstructive and adversarial has had a genuine impact. It was a deeply distressing inquiry in which to be involved, regardless of who you were or whom you represented. The trust's legal team was representing us in the context of unequivocally indefensible scenarios, and I know that the comments regarding adversarial conduct have had a deep impact on them as well.

All that said — I would like the Committee to understand and accept how seriously I say this — in the spirit of reflection and of owning the wrongs that are ours to own, where the inquiry panel concurs on that point, we own it and we will learn from it. On publication day in June, I said — I stand by it — that, if we pushed points of procedural fairness too far or pushed the letter of the law beyond the spirit of the inquiry, we accept that we did so and will learn from that. I assure the Committee that I do not shirk responsibility, and, as I liken Tom Kark's comments about the trust's attitude to those that I have heard at first hand from families about the fight that they have had over the years, I accept, on behalf of the trust, how hard it must have been to challenge an organisation that seemed defensive, paternalistic and unyielding. Throughout the report runs the reality of a power imbalance that, at its worst, raised its ugly head in the physical form of abusive behaviour, and, at its least worst — I use that phrase advisedly — manifested as disinterest, apathy and a disregard for checks, balances, rules and regulations. The lack of real-time governance and curiosity and the inability to triangulate information or, as Tom Kark put it, to simply join the dots had serious consequences.

The Muckamore inquiry report makes important observations in relation to assurance and risk management. Over the past number of years, we have taken meaningful steps towards improving our assurance and risk management arrangements, and much progress has been made. Risk and governance, in their broadest terms, are constantly evolving. The ongoing work will continue through taking careful account of the inquiry's findings and incorporating that learning as we continue to develop and improve our systems. For example, we are in the process of transitioning to a revised integrated governance and assurance framework, which is the system of oversight and controls that enables the trust's board to direct the organisation in line with its agreed corporate objectives; to monitor and manage risks as they arise; and to interrogate and challenge evidence relating to the safety and quality of the services that we deliver.

That work has been shaped by a number of important strategic drivers in addition to the Muckamore Abbey Hospital inquiry report. For example, the McBride/Hill report provided helpful advice and recommendations about governance arrangements and the need for further improvements to the trust's assurance system. Members will know that a patient safety and quality committee is being introduced as part of a wider effort to bring greater clarity and discipline to governance structures, including clearer differentiation between board committees, executive steering groups, assurance groups and operational activity. It is complemented by a stand-alone social care and safeguarding committee.

While the structure of how we manage the risks inherent in health and social care is transforming, I recognise that much of what was pointed to by the inquiry was the failure to bring those systems to life. I go back to what I said at the start of my remarks: actions need to be lived, and they need to be seen to be lived. To empower staff at all levels to act and to support a clearer assurance culture, we have introduced the well-recognised Alert, Advise, Assure, or triple A, model, which is designed not only to support formal upwards reporting to the trust board but to encourage sideways reporting across the trust.

There is significant activity in that arena across the trust: at trust board level; from within the medical director's office, which holds responsibility for governance and assurance; and with those staff, particularly our co-directors and senior managers, who live with and take decisions on risk, impact, escalation and governance every day. We are going forward with the aim of developing a strengthened and regular practice of consistent scrutiny and meaningful consideration of risks at every level, from daily operational to corporate to board, with the sole purpose of contributing to the quality and safety of our services.

The report's recommendations are helpful in that they show us clearly how to counter the convergence of failures at Muckamore by taking them further and broader across the HSC. The lesson for governance is that systems must actively seek out weak signals rather than wait for definitive proof of harm having occurred. There are vulnerable people in our care across the trust, and we operate in an HSC system that employs human beings, who are, by virtue of being human, flawed. If we are to be safe, it is therefore essential that we are constantly active in this area.

It is about real-time data, joining the dots, honest listening, respectful challenge, recognising safeguarding signals, having a real grasp of culture and how we do our business and, most importantly, putting the person first each time, every time. That is the safety message that each of us who is here today is drilling down throughout and across our organisation.

In the Belfast Trust, we have a dedicated Muckamore Abbey Hospital oversight group, which I chair. I have a number of work streams coming out of that group, all of which are led by a director, and all directors provide me, as chair, with regular written progress reports. It is a dynamic group, each member being charged with advancing the recommendations by assessing what gaps there are and what needs to happen to bridge them, which is important; and what is within our control and what is not. We work with Department of Health colleagues, actively participating in and reporting on progress. I know that the Committee will hear from departmental colleagues later about the regional arrangements that they have put in place.

To conclude, while we have accepted and will learn from our mistakes and, going forward, will be mindful of our attitude and our approach, the real legacy of the inquiry needs to be in the delivery of the recommendations and in how we support all people with learning disabilities and autism to live full, equal and empowered lives today and into the future.

Thank you, Chair. My colleagues and I are happy to take any questions.

The Chairperson (Mr McGuigan): Thank you very much for that, Jennifer. You talked about "shame, sorrow and anger", and you put on record the fact that you are "deeply sorry" for the behaviour. We will undoubtedly talk about the past today, but we want to go beyond that to talk about measurable action and proof of cultural change. However, I will start by looking back. A number of the inquiry report findings clearly identified the need for change in governance, culture and the treatment of families.

The report mentions the adversarial approach to the inquiry. I have met some of the families in the past number of weeks. They are concerned about the ability of the Belfast Trust to change its culture and to learn from some of the things that are clear from the inquiry report. Key to that is the adversarial approach that the inquiry team identified. I do not want to put words in your mouth, but I am getting a sense from you today that you are not totally convinced that Belfast Trust took an adversarial approach to the inquiry. I would like you to clarify that.

The Committee met Tom Kark a number of weeks ago. I do not want to put words in his mouth, but I think that I can quote him reasonably accurately. He said that he believed that some of the things that he has seen since from the trust have been performative. The Belfast Trust made an apology, but he said that no apology has been given to the inquiry team — the panel — in the context of that adversarial approach. I would like you to clarify for me, the Committee, the families and anybody listening the Belfast Trust's position on the inquiry's assertion that there was an adversarial approach. Further to that, can you tell us whether there has been any contact with the inquiry team since the report's publication?

Ms Welsh: Thank you, Chair. What I said was that I do not believe that there was any intention to take an adversarial approach, but it became clear through some of the conversation that the approach could have been construed as adversarial. I genuinely believe that there is that distinction. It was about wanting to ensure procedural fairness from a legal perspective, but, unfortunately, that detracted from the spirit of the inquiry, which was about the abuse, the neglect and the cruelty.

The Chairperson (Mr McGuigan): We are stuck for time, so I will probably interrupt. Apologies for that. I do not want to seem rude, but I want to get to the important parts.

On culture, we are immediately starting off with a difference of opinion: how the Belfast Trust sees something and how others see something. That is certainly vital. It is vital from the families' perspective. The Committee has evidence from long before your time of the need for cultural change in the trust.

Ms Welsh: Let me be very clear, Chair. We have talked about culture before. I was here in October last year, shortly after I took up post, and I acknowledged the need for a culture change to happen in the Belfast Trust. I talked at that stage about sustained cultural change being a three- to five-year journey. We absolutely know that. I think that we have begun that journey. Speaking more broadly, we have a draft people and culture strategy that we hope to take to our trust board very shortly. Sitting alongside that will be a new respect and civility framework on the behaviours that we expect to see and, equally, the behaviours that we do not expect to see.

Mr McGrath: But, Jennifer, —.

Ms Welsh: In relation to this specifically, it is important to paint the broad picture. I have written to the families about this. I absolutely accept that the approach was perceived as adversarial. At the outset, people did not intend for that to be the case, but I completely accept that it was.

The Chairperson (Mr McGuigan): I know that the engagement was primarily through lawyers and solicitors, but I suspect that it was overseen by senior people in the Belfast Trust.

Ms Welsh: Yes, and I have to take responsibility for that as the chief executive now. I am really sorry. I have not apologised to the inquiry team —

The Chairperson (Mr McGuigan): That will be important.

Ms Welsh: — but I am very happy to do that if Mr Tom Kark had that impression. I am very happy to meet Mr Kark. I have not done that to date. If that is an important step in this, I absolutely will do it. We have already apologised to the families. I want to be very clear that this is not performative; I am not being performative. I am here genuinely. I have met genuinely with families, as has Stuart. I understand that it is also difficult for families. They need to see action. My words are one thing, but our following up and delivering on the recommendations and demonstrating that we are serious about change are another.

The Chairperson (Mr McGuigan): Action is very important. Maybe I am wrong on this, and I will ask the Department a similar question. When we met Tom Kark, we asked him whether there had been any engagement with the Department. I find it difficult to understand how, after such a very serious report —. Having read the evidence, I cannot comprehend how people who were tasked with looking after the most vulnerable could do some of the things that they did or how people in senior responsible positions allowed it to happen for so long. Sitting here today, I still find that difficult to comprehend. I also find it difficult to comprehend how, in the three or four months since such a serious report was published — a report in which the inquiry has produced and made public its findings, most of which revolve around how the Belfast Trust behaved — there has not been engagement between the Belfast Trust and the inquiry to ask, "What did you mean by this? Explain the details. How can we do what you're suggesting we need to do better?". I find that lack of engagement baffling.

Ms Welsh: I am very happy to engage with the inquiry. We took some time to go through the report in detail. The purpose of the ongoing interaction between the respective legal teams was to clarify some of the points in the report. The report has given us a clear set of recommendations on the way forward, and that is what we have been focusing on. We have been drilling down into the detail and looking at which of the recommendations are straightforward to implement, which of them we already have in place, which of them we will have to collaborate on with our trust colleagues across Northern Ireland and which of them we will have to engage with the Department on in order to get clarification or agreement on the way forward.

The Chairperson (Mr McGuigan): And, in looking at that —.

Ms Welsh: I do not want you to think that we have not been taking it seriously; we absolutely have been.

The Chairperson (Mr McGuigan): OK. Well, in terms of taking it seriously —.

Ms Welsh: I also want to make it clear that there is no intention of showing any disrespect to the inquiry — absolutely not. The chair and I are committed to delivering on the recommendations and to working with and listening to families. That is our priority.

The Chairperson (Mr McGuigan): Does the Belfast Trust unequivocally accept all the recommendations of the inquiry relating to the Belfast Trust?

Ms Welsh: Not all the recommendations are for us. Some are for the Department or other bodies. There are some things on which, as I said, we will need clarification from the Department. For example, some recommendations relate to the appointment of an executive lead for clinical and social care governance. That is not a decision that we can make on our own; it requires legislative change. In principle, however, we accept all the recommendations, yes.

The Chairperson (Mr McGuigan): OK. You talked about the oversight group that you chair, which is specific to the Muckamore inquiry. When will the families, the Committee and the public see actions that we can monitor? When will we see improvement and implementation?

Ms Welsh: We can already demonstrate some of it, but our reporting line goes up to the Department of Health, and we will work with the Department on when it wants to publish any of the recommendations. The Department is working with us and with all the trusts, and I do not want to pre-empt what some of my colleagues may say in a later session.

The Chairperson (Mr McGuigan): This is the final point from me on this. You said that you and the chair take responsibility for all that has happened. Are the chair and you now taking responsibility for ensuring that the recommendations in the inquiry report are implemented, that culture change will happen in the Belfast Trust and that the Muckamore families, the Committee and the wider public will witness evidence of that cultural change?

Ms Welsh: Yes. That cultural change started last autumn with the work on developing the people and culture strategy. We are absolutely on that journey and committed to taking forward the recommendations. Absolutely.

Professor Stuart Elborn (Belfast Health and Social Care Trust): The board is absolutely focused on that. We are first out of the blocks — at least, early out of the blocks — in establishing a patient safety and quality committee. That committee had its first meeting in May. We are laser-focused on making sure that we get appropriate assurances and detect potential problems. We are working hard with our whole organisation to change the culture. That is evidenced, in part, by the fact that our first reaction to the report was to go to the families. We need to co-create with families for the future, and I encourage everyone involved to think about people with learning disabilities and autism who are now in the community and the fact that there are new and different risks for them. We need to take the learning from the Muckamore Abbey Hospital inquiry and apply it for the future benefit and support of people with learning disabilities in the community.

The Chairperson (Mr McGuigan): I will open it up for other members now.

Mrs Dillon: Thank you, all, for coming. The Chair has just referenced one of the issues that I want to address, which is how we measure the implementation of the recommendations. I accept that you may have started, but I need to understand whether you and the Department are working to a plan that we can sit and monitor as a Committee.

I am looking at all of this from the perspective that I have in my other role as a member of the Policing Board. We do all the same things around culture change and the implementation of recommendations. Even when the PSNI accepts recommendations, it does not necessarily mean that it will implement them. We get all sorts of reasons why they cannot be implemented. Therefore, I need to understand whether we will get an implementation action plan that we can follow, measure and look at regularly to see where we are with those. Do you want to answer that first?

Ms Welsh: I will answer that bit first, and then I will hand over to my colleague Dr Sloan. The permanent secretary chairs a weekly meeting that Peter or I go to, and other detailed work has been going on with all the directors of mental health and learning disability across all the trusts, and that feeds up through into the Department. I will hand over to you, Peter.

Dr Peter Sloan (Belfast Health and Social Care Trust): As Jennifer said, much of our focus in the past three months has been to understand the report and recommendations in detail. Following that, we did a significant piece of work looking at the improvements and changes that we have already made, which was to give us our baseline, and to map that baseline against the recommendations.

That work has been shared with the Department, and we have engaged with it, the strategic planning and performance group (SPPG) and colleagues from other trusts to think about that structure so that the recommendations and implementation can be mapped and progress can be seen. We have taken time over that. There are 106 recommendations, and we want to be sure that our structure and oversight are right, that we are making progress and that the changes that we are making are being felt on the ground.

You asked about how we will know that implementation has occurred. That has to be front and centre. The service users and their families have to feel the changes in the services that we provide. Engagement with service users and their families will be a big part of how we implement the recommendations. There will be various levels of engagement. It will be a very big piece of work across the region. There will be representation from families at a regional level for the most senior oversight. There will also be representation from families at a trust level. Again, we have put thought into how we do that, and it is important that we speak to families and listen to how they want to engage and work with us.

One improvement that has already taken place is that we have set up an established family engagement forum. The next meeting is on Thursday, and engagement on the recommendations is on the agenda. Our plan is to open up the discussions at that point and hear from families about how they would like to work with us.

As Stuart said, our ethos and thrust going forward are about partnership and meaningful engagement. One of the most significant findings from the inquiry is that service users and families were not heard. Therefore, it is not about tokenism and sitting on committees; it should be about proper, meaningful partnership. We want to open those discussions on Thursday.

We will also have our own separate trust engagement event because we recognise that, while our forum is established and works well, it might not be the preferred method of engagement for all our families, and we want to try to reach out to as many families as possible.

That is just a flavour of some of the work that we have been carrying out in recent months.

Mrs Dillon: We need to work out as a Committee how we monitor that. I am glad to hear that about the other trusts, because that was going to be my next question. I do not think that any of us should kid ourselves that this is Belfast Trust-specific.

Muckamore may have been the scandal that broke, but I guarantee you that families are not being listened to across every trust. That relates to young people and adults with learning disabilities and people with mental health issues.

The next part that I will come to, which you referenced, Chair, is the culture. I dealt with families before the Muckamore scandal broke. Families came to us and said that they had concerns, and I can tell you that there was an attitude of, "We know better than you" from health professionals. As an MLA, I thought that, as they were health professionals, they probably did know better than me. However, as someone who has been in this job now for 10 years, I have realised that I should never accept that anybody knows better, not necessarily than me, but than a parent of a young person whom they have looked after like an egg for years, who then went into Muckamore and their condition deteriorated unbelievably over a very short time. They were told that it happened because of the difficulties that their young person had, yet they had none of the issues that they were displaying prior to going into Muckamore.

I am thinking specifically of one family that I dealt with. I will not reference the family specifically because I do not have permission to do that today; I have not asked for it. The family consistently raised concerns and showed me photographs of their son before he went into Muckamore. It was not the family's choice for him to go into Muckamore. I saw what was sitting in front of me eight or nine years later, and there was no comparison with that young person. It was unbelievable how much he had deteriorated in every way, in his physical health and everything else.

How do we get that culture change? I understand that medical professionals have gone to university, studied hard and want to understand their profession. They genuinely believe that they want to do their best and that they know best, but how do you get past that? They do not always know best.

As an MLA, I have to do it all the time. I accept that I do not necessarily know the answers to everything. I have to be prepared to say, "I do not know everything", so I listen to the people who are talking to me. It does not matter what position you hold, and I do not know how we are going to break down that culture because, honestly, I see it every day. It is not just in the Belfast Trust; it is across every trust.

How do we break down that culture for people to understand that it is not a diminution of their position to accept that they do not know better than people's families, patients or the people who come to them? That does not take away their ability to be a professional and to understand their profession. Actually, they would be a much better professional if they genuinely listened.

How do we genuinely change that culture, Jennifer? I am not saying that anybody here does not want to do that, but how do we genuinely change it?

Ms Welsh: I will start, and I will look to colleagues as well. There is no doubt that what happened in Muckamore was absolutely shameful. The CCTV footage shows what happens when people do not provide positive behavioural support, and you can see situations where they deliberately frustrated our service users — our patients — which exacerbated their behaviour. That is not a situation that would have occurred with a family member because they know how to manage them.

I have given the issue of expert experience a lot of thought after meeting some of the families. My dad was involved in healthcare for many years, and I would describe my mother as an expert carer. She was very fortunate to have the support of a really good GP and to have a really good relationship with them. If you do not have that, what does that mean?

One of the most important things here is the changing service model. The institutional care that allowed that situation to flourish has gone. I will ask Peter and Olga to talk about the very different service model.

On that most important bit about how we work with families and listen to them, the Patient and Client Council has done a really good piece of work on the "People to Partners" approach and how individuals and family members are more partners in care. That is a significant cultural change for a lot of staff across all of Health and Social Care, but it is something that we must take forward.

Mrs Dillon: Again, it is about how you monitor that to make sure that it is happening. We can set up all the governance and policies, and there is institutional memory. We all know now what happened, and you said that you saw on the CCTV footage what happened to those people. I never had to view that. I cannot even begin to imagine it. The problem is this: how do we absolutely embed that institutional memory and ensure that we do not lose it and thereby lose the importance of listening to families and understanding that they will know better than anybody else? It is not even about those who abused those young people; it is about those who did not listen. People were allowed to abuse because people at higher levels did not listen. That is the honest truth. Families appealed to others, as did professionals, to listen to the fact that they were concerned about what was going on with those young people. The culture change needs to happen at every level. It is not just about the carers who work directly with young people but about every single person in the health service.

Ms Welsh: I completely agree.

Mrs Dillon: How do we get underneath, understand and monitor whether families feel 100% that, when they speak to a health professional at whatever level, they believe that they are being listened to and that the change that needs to happen or the concerns that they are raising will be genuinely heard and addressed? That does not mean that their concerns will always be 100% right, but people will have been listened to and will get honest answers, whatever they are.

Dr Sloan: First, I wholeheartedly agree with you. To echo Jennifer's words, the abuse that we saw on the CCTV footage, what we have heard from the families in the time since and what we have read about in the inquiry report was appalling and shocking to all of us. You made the point that, underpinning our current model, the service user — the person — needs to be front and centre. That did not happen. That was one of the major findings of the report, along with the importance and weight that we should place on the family's involvement, which Jennifer referred to, and the fact that families and loved ones have such a value in the service because of the understanding that they have of their loved one's condition and behaviours and the care that they receive, which can be fed up to managers of the service. We have talked about partnership, and that is the key to all this.

From a governance perspective, our new systems are not just about the collection of various types of data but about proactive governance. While Muckamore was still running as a hospital, we implemented real-time patient feedback, where we collected feedback and views from patients. Now that the model of care is predominantly delivered in the community, that feedback loop will be rolled out into community settings. We have already started in daycare settings, and our next step will be to roll it out into residential care. Engaging with families is part of the intelligence that we collect from all our residential settings.

As much as the shift in the model of care brings about huge benefits in betterment and in enabling individuals with learning disabilities to lead fuller and more meaningful lives, we also need to be open about the change in the risk profile. We acknowledge and understand that. Our patients are more spread across community settings, so we have had to change our governance focus in the service accordingly to allow for those changes. We now have a governance lead whose role is to work solely in commissioned services in residential settings to gather, collate and, importantly, triangulate that data when it is gathered. You will know that one of the other findings from the inquiry, which is connected to all of this, was the fact that, while a lot of data was being gathered, it was not necessarily connected in order to enable people to understand the bigger pictures. The governance lead's role is to gather that together, present it to the senior team in the division and feed it into the new board assurance framework that Jennifer referred to.

Part of that new structure is quality assuring the placements that our patients — our service users with learning disabilities — live in. Unannounced quality-assurance visits will be carried out to get a sense of the care that is being provided out in the community. Part of that will involve gathering information from patients and families. We have implemented structures within our governance system that collects information and data from patients and families. We also recognise some of the concerns that came out of the inquiry about being listened to. A finding across the whole inquiry has been that patients and families did not feel as if they were being listened to. We have to take that on board. That will be our focus, going forward.

I want to make one more point. I am not saying that there will always be agreement between the service and the family. You made reference to that. That is not an easy issue to resolve, and there is work that we still have to do in that regard, but, again, underpinning it all should be the needs and best interests of the patient. At times, when we are unable to agree on a plan or may not be able to meet a family's request, we have to have open and respectful dialogue and be clear about why that request might not be able to be met.

Ms Welsh: I will comment, and I know that Olga wants to comment as well. I talked in my opening remarks about the patient safety and quality committee. Sitting alongside that we have a stand-alone social care and safeguarding committee. It is chaired by the vice chair of the organisation. That is about getting at the heart of the curiosity and joining the dots. It is actively seeking information from services. In the past, there was perhaps more of a passive approach of waiting for information to be presented. That is not something that we as a board are doing. It is about actively seeking information from services, seeking assurances on engagement with families and ensuring that families are being listened to.

Ms Olga O'Neill (Belfast Health and Social Care Trust): How we train and educate our staff, as was mentioned in the inquiry, is fundamental to cultural change. Going forward, we are holding values-based interviews. As you come into the organisation, our induction is focused on the education of our staff on our values, our expectations, what we expect as an organisation and what an employee should expect from us. Our cultural work is the ongoing maintenance around all that. Person-centred care is at the heart of how we train our future generations. The work that the Regulation and Quality Improvement Authority (RQIA) has done around being human is fundamental to that work, as is the ability to demonstrate evidence that the care that we are providing is focused on the person.

You said that a parent knows their child much better and a loved one knows their relative much better. They know when they are not well and when they are sick. There is no hierarchy in that knowledge. It should be partnership knowledge and about sharing that information alongside a health professional. It should not be a case of, "I'm a registrant", or "I've been to university. I know better", because I absolutely do not. That person spends a moment in time in healthcare. It is about supporting them back into the community where they will live with their family and about ensuring that they have the networks and support mechanisms to help them to live their best life. I completely agree that the fundamental change needs to come from how we train and educate our staff.

Mrs Dillon: Sorry, this is my last point, Chair.

The Chairperson (Mr McGuigan): Very quickly.

Mrs Dillon: In dealing with difficult issues, when you may not be able to meet a family's request, a family can accept it more easily if they feel that you are speaking to them as equals and taking them on as equals. That is important. If they think that they are being talked down to or that you think you know better, their backs will be up, and rightly so. They think that you think you know better. That is always a fear for a family, particularly as it was for the Muckamore families.

Professor Elborn: In the greater system, we are about delivering better outcomes for the people whom we have the privilege and responsibility of looking after. That collaborative approach gives better outcomes. That is clear. Even when there is disagreement about what to do next, having that engagement increases adherence to treatment and the engagement of patients in whatever therapy is being suggested. There is a shift going on in medicine. A pivotal book, 'The Patient Will See You Now' inverts the power relationship. It is around the patient that we have to focus and show respect, and we have to empower them, because they are delivering their own healthcare. The individual or family has to do the business of delivering healthcare on the advice of professionals in order to deliver better outcomes. It is really important that we have a patient safety and quality committee. Safety and quality have to go together, because we are dedicated to improving the health of our population.

The Chairperson (Mr McGuigan): It is 10.30 am. I will allow this session to continue until 11.00 am, but I will close it at that point because we have another session with the Department. I want to be fair. We have three members remaining. We want the information — it is vital — but I appeal to you to shorten your answers slightly.

Miss McAllister: Thank you very much for coming along today. I will try to get straight to my questions. We have all been working with Muckamore families over the past few years. We have also been working with families whose loved ones have been in other care settings, and some families whose loved ones moved from Muckamore to another care setting and were then subjected to abuse. It is horrific that that was allowed to happen in the first instance.

My first question is about culture: have you had a very basic conversation with line managers throughout the trust about the attitude problem when it comes to how families are spoken to? That concerns not just adult patients but under-18s who have learning disabilities and/or autism. I have witnessed it; I have been in meetings with families, after which they say, "They were the nicest to me that they've ever been because you were there". It has been experienced by other family members, who have then almost fought back and been as robust, and others who felt that they could not be robust and were really spoken down to. There is a very basic attitude of disrespect in the way in which those people have been spoken to by so many in the Belfast Trust, which has continued to this very week. Has there not been even a very basic conversation about not treating families like crap and not talking down to them? There is a very basic human-level attitude problem. You do not need a culture document to address that.

Ms Welsh: It is extraordinary that we have to have a conversation about how we, as human beings, behave towards one another. It is appalling. I have been very clear about such things in my messages throughout the organisation, but, clearly, more needs to be done. If families are saying to you, "That's the best it's ever been because you were in the room", that tells me that we still have a real problem, and a significant one —

Miss McAllister: To be quite frank, you do.

Ms Welsh: — in certain places. Clearly, there is focused work that needs to happen at that basic level of human decency, which is really disappointing.

Miss McAllister: Has there been a conversation? I know that it has been written and that people get emails, but, at a very basic level, has there been a conversation? You do not need degrees, documents, policies or consultations to say, "Treat people better, and stop talking to them in the way that you do". Has anyone ever faced any sort of disciplinary procedure because of the way in which they have spoken to people or been pulled up on it? It needs to start there.

Ms Welsh: I cannot speak about whether there have been disciplinary procedures. When we are alerted to concerns, we deal with those in relation to individuals. I have been very clear in my speeches and podcasts to the organisation about the behaviours that I expect. The respect and civility framework that we will launch towards the end of the month is very clear about the behaviours that we expect to see and, equally, those that we do not. However, based on what you are saying, we need to be more blunt —

Miss McAllister: You absolutely do.

Ms Welsh: — and specific, because what we are currently doing is insufficient. Thank you for raising that issue.

Miss McAllister: I am more than happy to provide other examples. Again, it is about not just adults but children.

Peter talked about when there is not agreement between a family and the trust. I recognise and respect that that is not always going to be possible and that it needs to be dealt with. From our perspective, when it comes to families seeking and getting help with moving to residential, it is often too late to prevent family breakdown. They need that extra help and support. Where is the line between agreements with families and trusts? What do you use then? What happens then? I understand that it is different for adults and for under-18s. What happens then?

Dr Sloan: There will be a group of patients with whom we work who will have the capacity to make their own decisions. In such cases, their views are paramount. They will decide on their own care themselves. For individuals who lack the capacity to make decisions — the group to whom you are referring — there is a best-interest approach, and there is a legal framework around that. Despite the lack of capacity, we obviously take the views of the patient on board. That should be, as I have always said, front and centre. We also take the views of the family. The difficulty can arise if there is a disagreement about best interests or assessed needs. That bit is difficult to resolve, and we still have to work on that.

Miss McAllister: How can you assure us that best interest is not always the easiest option for the trust? I respect that, sometimes, it is difficult. There are budget issues. Sometimes, there is a perception that best interest is the easiest option for the trust regarding placement, care and other issues — not specifically the care plan, but more the future of the individual.

Dr Sloan: By "the future" I presume that part of that is the residential care and the care being provided.

Miss McAllister: Yes.

Dr Sloan: The best interests will come down to the assessed needs. Assessed needs will be determined by the multidisciplinary team (MDT). That is an independent decision, bringing together lots of different professionals and lots of different expertise. It is not reliant on the opinion of one individual.

Miss McAllister: Does the trust always explore all options when it comes to residential placement? For example, parents may approach, saying, "What about this?". Does the trust explore or does it just stick within its financial limits?

Dr Sloan: No, no. We would explore the preferences of the patient and the family as part of that process. That said, it might not always be possible to meet those requests.

Miss McAllister: My next set of questions is on the inquiry itself. I understand that, through public inquiries that are set up — a bit like with ombudsmen's cases, whether that be the Police Ombudsman or the Public Services Ombudsman — there is often an investigation of the what, when and how, and, sometimes, the why is missing, and it is subjective.

Regarding the CCTV and its installation, which, I assume, followed the initial review that took place, can you shed any light on why the fact that the CCTV was installed at Muckamore and knowledge of it being there did not work its way up the chain? Has there been any further assessment or have you just left it to the inquiry to deal with? Did the trust have an examination of that?

Ms O'Neill: The CCTV was implemented, and why it was not noted that it was actually active at that time was reviewed. That appeared to be caught up around the development of policy. There was significant delay in relation to agreement around the fundamental, practical aspect of the policy, such as when the CCTV would be turned on and when it would be viewed. It was installed as an additional safety measure, but it was not recognised as having been active from the time of its installation until the policy was agreed.

Miss McAllister: How widely was it known, though, that CCTV had been installed at Muckamore? Has that ever been looked at or examined by the trust?

Ms O'Neill: It is very visible. It is easy to spot and to demonstrate. It was procured through an external company to be implemented, so it would have been known within the organisation through a procurement process, as well as a request to build a business case around the implementation. However, whilst it was turned on, the organisation was not aware that it was turned on until the policy —.

Miss McAllister: It seems that it was put in place because of adult safeguarding issues. I assume that adult safeguarding would be on your register of risks, as a trust body, given that you have looked-after people in your care. We have information that that was never placed in the trust board's knowledge. Was it placed on the register at all? Will you undertake to rectify that with any other CCTV that is put in place?

Professor Elborn: We absolutely will have it on our risk register. I do not know for sure whether it was on it at the time, but we will absolutely look back at that. We are really focused on early alerts now. If they were putting in CCTV, the alert had already been there and there was clear concern. We need to reflect on that a little more.

Interestingly, there is a challenge around the use of CCTV. A number of families are very positive about it, and others are very negative about it.

Miss McAllister: It is a difficult one.

Professor Elborn: It gets into issues of the human rights of the individual in either their community or a care home. That is an active debate and is one of the inquiry recommendations. We are trying to figure out how to work with individuals with learning disabilities and their families on the added safeguard, as some see it, of CCTV in their living space.

Miss McAllister: That has come through in the Adult Protection Bill as well.

Professor Elborn: Yes.

Miss McAllister: One of the other recommendations is on the placement of patients and their discussions with families. Jennifer, will you give the Committee an assurance that you will personally ensure that there is an overview or examination of all people who were inpatients in Muckamore to look at where they are now, whether things are going well, whether we can improve their care, whether we can improve family and trust communication and whether anything more needs to be done?

Ms Welsh: We will take that forward as part of the new committee structure, which is overseen by members of the trust board including the chair, the vice chair and me. That is the mechanism that we will use.

Miss McAllister: Thank you.

Mr Donnelly: Following the publication of the inquiry report, there were comments that the trust was adversarial. I want to check your wording in relation to that. You said that you could see how it was "perceived" as being adversarial. Do you accept that the trust's behaviour during the inquiry and the tone of the correspondence was adversarial?

Ms Welsh: I can certainly see how people felt that it was adversarial. It is not an approach that I would have wanted to take.

Mr Donnelly: That was not my question. Do you accept that it was adversarial?

Ms Welsh: Yes.

Mr Donnelly: Yes. The trust was going to reflect on its approach — its defensive stance. What are your reflections?

Ms Welsh: The correspondence in the early days of the inquiry felt more collaborative and constructive. At some point along the line, the correspondence from both parties became difficult and, I think, adversarial, which was a great detriment. I think that people genuinely thought that they were moving forward on points of procedural fairness to ensure that the correct information was provided to the inquiry.

It may be easiest if I give an example. There is a concern that the trust was perhaps asking that records be taken in preference to the voice of the family. An example was given that a particular resident had never had access to dental treatment. The records — not trust records, but dental records — showed that dental treatment had been provided. That was a point of procedural fairness to demonstrate that, actually, treatment had been provided. The point was delivered in probably a very legalistic tone, but that is an example of what was described as being adversarial.

It is really disappointing that people's genuinely trying to do their job in the legal setting of a public inquiry has been allowed to detract from the spirit of the inquiry. There is no doubt about the abuse, the neglect and the absolutely shameful things that happened at Muckamore. They should never have happened: we are absolutely clear on that. I am really disappointed that the adversarial approach is detracting from that and from the experience that families had; the experience that their loved ones had in Muckamore; and the most important thing, which is the recommendations that have come out of the inquiry and our delivery of them, working with families to do that.

Mr Donnelly: Thank you, Jennifer. I am glad that you have accepted that it was an adversarial approach. Building on that, what will you do differently now? What will be the trust's approach to another inquiry, if there is one? We have had a couple in the past few years. What will be different?

Ms Welsh: It is about what we talked about earlier. It is about listening to and working with families. I hope that we will never again be in a position of having a public inquiry. It is shameful that Northern Ireland has had so many public inquiries across health and social care services. Our departmental colleagues will be coming in shortly. A huge amount of work has been done through the inquiries implementation programme management board to ensure that we take the learning from inquiries. That is part of what we have reflected here today about the need for culture change; the need for us to work with patients and families; and the whole concept of people as partners and working differently together.

Mr Donnelly: If there is another inquiry, how will you guarantee that there will there be a less adversarial approach?

Ms Welsh: I reiterate that I genuinely do not believe that anybody set out to be adversarial. The approach from both parties changed at a point during the inquiry. I genuinely believe that people felt that they were trying to conduct matters with procedural fairness. We would certainly want to be open, honest and transparent with any inquiry. Tom Kark recognised that that was the case in this inquiry: it is important to say that.

Mr Donnelly: OK. I note that you still have not met Tom Kark or the inquiry.

Ms Welsh: I am happy to do that.

Mr Donnelly: OK. That would be a good idea.

You mentioned that not all the recommendations apply to the trust. Of the 106, is there a specific number that, you have accepted, apply to you?

Ms Welsh: We are looking at it in the round. Even where there are recommendations for the Department, we may have a role to play. I will hand over to Peter for the detail.

Dr Sloan: I do not have an exact number. Jennifer is right that we will have a role in implementing even the recommendations that are not attributed directly to the trust. We will work collaboratively with the agencies that own those recommendations. Overall, we accept the recommendations. There are some that contain details that we will need to tease out in order to understand them a bit more clearly. We will have those discussions with the Department — we have already started to have them — but we accept the vast majority at this point.

Mr Donnelly: OK. I want to build on what Linda said about having a plan for implementation. It needs to be a visible plan so that we can see that all the recommendations are being accepted and progressed and that there is no dispute between you and the Department over who is responsible for particular recommendations.

Dr Sloan: Some of the recommendations contain detail that it may be beyond the trust's gift to implement, including the appointment of certain officers and roles. We will work with the Department to clarify the practicalities of those appointments. The vast majority of recommendations are about service reform, and we accept those recommendations. I am sure that departmental officials, when you meet them, will talk you through the structures that have been set up. The recommendations have been themed and brought together so that they can be implemented in groups according to those themes. That is how progress will be mapped and how trusts will feed in. There will be work streams that will be chaired, and trusts will feed into those work streams. It is very much a regional approach, not an isolated Belfast Trust approach. We work very closely, as a region, on mental health and learning disability. The five trusts meet very regularly, and we have already talked about the recommendations at length and how we plan to implement them. Some of that work will be regional work.

Mr Donnelly: Thank you.

Mr Robinson: Thanks, Jennifer. One of the submissions that we received from the Muckamore families states:

Quite rightly, the Muckamore families said:

Do you agree that, if that was the stance, it was an incredibly arrogant stance for the trust to take? Will you also detail to the Committee who in the trust has been guilty of that kind of approach and stance?

Ms Welsh: As I say, I genuinely do not believe that it was anybody's intention to be adversarial in their approach to the inquiry; I really do not.

Mr Robinson: Was it an individual?

Ms Welsh: No, it was not an individual. There is an oversight group that had access to all the information, but, ultimately, it came down to a small team working with our legal team from the Business Services Organisation (BSO) department of legal services (DLS) and with trust counsel in relation to the provision of information. I understand and accept fully why that was very difficult for families to read, and all I can say is that I am really sorry about that. Again, it comes down to procedural points of law that normally do not come into the public domain. I am advised that, in other inquiries, that is the nature of the conversation between the legal teams and that, ordinarily, that information does not come into the public domain. What happened was highly unusual.

As I say, we accept everything that Tom Kark said in his report. We accept the recommendations. I am really concerned about this detracting from the important work that the inquiry did — the finding of the abuse and neglect — and what we do to change services and rebuild trust with the families, which we know will not be easy. I genuinely believe that there is a willingness on the part of families to work with us. There is a genuine attempt from us to say, "We are serious about this and serious about going forward with the recommendations".

Mr Robinson: The report was also critical of the legal team that you referred to. What learning has there been? Is that an in-house legal team or one that is contracted in?

Ms Welsh: All the trusts in Northern Ireland work very closely with the department of legal services, which then appoints counsel to support the trust. It is not technically an in-house team, no.

Mr Robinson: Has there been, or will there be, a review of that legal team?

Ms Welsh: There have been conversations between me and the Business Services Organisation, which houses the department of legal services. Again, I do not believe for one moment that there was any intention to be adversarial. It was about points of procedural fairness.

Mr Robinson: That is it, Chair. I am conscious that it is almost 11.00 am. Thanks.

The Chairperson (Mr McGuigan): There are no more questions, so I thank all five of you for coming before us today and taking our questions. The Committee does not intend to let the issue go. It is an important aspect of our work and we will continue to monitor progress, both on wider culture change in the Belfast Trust and on this specific issue. Again, thank you very much for coming before us.