Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome, from the Department, Mark McGuicken, director of disability and older people; Dr Ciara McKillop, director of social care, mental health and disability; and Mr Sean Scullion from the Muckamore Abbey review team. You are all very welcome. Thank you for coming before us today. I refer members to the papers at page 795 of their main pack. The Department has asked that, during this briefing, members give some thought and sensitivity to the families who are meeting the Minister tomorrow. I will pick up on that point after Mark or whoever gives us some introductory remarks.

Mr Mark McGuicken (Department of Health): No problem, Chair. Thank you for the opportunity to brief the Committee today on the work that the Department is taking forward in response to the Muckamore Abbey Hospital inquiry final report. As you say, Chair, I am joined by Ciara and Sean, and we will do our best to answer whatever questions the Committee has after making some opening comments. If you are content, Chair, I will begin by providing a summary of the progress since the inquiry published its report, and then we will be happy to take questions. For ease, I will refer to Minister Nesbitt when talking about some of the work that was taken forward before he left office rather than saying the "previous Minister" all the time.

As you are aware, Minister Nesbitt set out his initial response to the report in his oral ministerial statement on 22 June. As part of that statement, he immediately accepted recommendation 2, which requires the Department to make public whether it accepts the recommendations or to explain why it does not within six months, so by mid-December. Minister Nesbitt was very clear that he expected the Department's response to be made well in advance of that deadline.

Minister Nesbitt then convened a quality and safety summit on 30 June that brought together Health and Social Care (HSC) system leaders, including trust chief executives, chairpersons and the chairs of the patient and safety quality committees. At that meeting, he laid out his vision on the responsibilities and critical role that the HSC organisations, particularly the trusts, hold in strengthening patient safety, culture, governance and accountability. In late July, the Minister wrote to attendees of the summit with feedback on the outcomes of the report.

On 8 July, the Minister and the permanent secretary met approximately 46 individuals who either had been patients at Muckamore or were family representatives. The meeting that was independently facilitated provided an opportunity for all those impacted by the events at Muckamore to air their concerns and views. At that point, the Minister made it clear that that was the start of a regular engagement process with affected families.

Since then, of course, we have had a change of Minister. To be clear, Minister Butler shares his predecessor's approach to implementation of the report. He has made it clear that he wants to meet and hear directly from the families before he provides an update to the Assembly on progress. As you have noted, Chair, that meeting is scheduled for tomorrow afternoon, and the Minister intends to make a statement shortly thereafter to the Assembly.

The Department is progressing work to implement the inquiry recommendations in line with our guidance on responding to public inquiries. However, I acknowledge that some families may feel that they are not seeing evidence of progress as quickly as they would like. The meeting with the Minister tomorrow will allow them to be updated on what has happened since the inquiry published its report. However, it is important to say that I believe that the approach that the Department has taken to date has been proportionate to the scale of what is required to deliver the 106 recommendations in the report.

I will give an overview. A range of preparatory work has been undertaken in the Department. That includes an initial thematic analysis of the recommendations in liaison with the relevant stakeholders, in both the Department and wider HSC, to inform a determination on whether recommendations should be accepted in full, in principle, or in part, and that work continues. It has included the identification of any interfaces and alignment between the Muckamore recommendations and any other work that the Department already has in train. We believe that that is necessary to avoid any duplication or confusion about who is responsible for taking forward the recommendations.

As part of that work, Dr Patricia Donnelly has carried out an independent assessment to assess any crossover between the Muckamore inquiry recommendations and those from other inquiries that the Department is also implementing. Patricia assessed all inquiry recommendations to see where there are crossovers with the Muckamore recommendations. The recommendations have also been considered and mapped on to recommendations from other key strategic initiatives relating to learning disability: for example, the work on the new learning disability service model, the Adult Protection Bill and the 'Equity of Access and Outcome' report on the future of registered nursing learning disabilities (RNLDs).

The strategic planning and performance group (SPPG) has written to all trusts to ask them to provide an assessment of each recommendation, including the current position and any work that is already in progress to address those, in order to identify any gaps and potential next steps for implementation. Comprehensive responses have been received from all trusts, and they are now being considered as part of the work to develop the next steps. That work will help us to develop timescales for delivery and identify recommendations that require further consideration and resource. In addition, departmental officials have met the director for mental health, intellectual disability and psychological services to ensure that a coordinated response is implemented across all trusts. We have agreed to hold monthly meetings to discuss the inquiry report and wider learning disability issues.

The Chief Nursing Officer also held a workshop on 18 August with trust executive directors of nursing, wider HSC learning disability leaders and representatives from the Department, the Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) and the Public Health Agency (PHA). Workshop participants discussed the inquiry findings; key necessary actions; ownership and accountability; and measures of success. They also considered where work had already commenced on recommendations. Drawing on that engagement, we have developed a proposal for an implementation oversight structure, which involves grouping the recommendations thematically in 10 work streams. That will have another structure on top of it, which will report to a structure that the permanent secretary will install. We will look at how we map that against the inquiries implementation oversight group, as per recommendation 1.

We have also carried out initial scoping work on the recommendations about establishing a consultation group and a redress working group, as per recommendation 106. We are preparing final advice to the Minister on both options. We have sought an independent assessment of proposals on engagement with families, which will inform that advice. Of course, we will engage with families on those options before anything is agreed.

Two recommendations sit outside the scope of the Department of Health: recommendations 88 and 89 are for the PSNI and DOJ respectively. The Minister of Health wrote to the Minister of Justice on 27 August, requesting her assessment of those recommendations.

Where we can, we will address recommendations quickly. However, I am sure that you appreciate that some require more in-depth analysis, and, inevitably, a number will have resource implications, which will need to be considered carefully. Some recommendations may require legislative change. Again, we need to consider those to see what we can bring to the Assembly.

I turn to accountability and oversight. Given the number of inquiries into HSC services, the Department has set up a directorate to ensure that any thematic issues arising from the reports are addressed and that implementation of the recommendations is consistent. Oversight and accountability are provided through the inquiries implementation programme management board, which is chaired by the permanent secretary. The board ensures alignment and accountability across the Department and the wider HSC for the delivery of recommendations. The Muckamore Abbey review team, which Sean heads up in my directorate, is leading the response to the inquiry report and its recommendations. We will provide regular updates on activity and forthcoming work to the implementation programme management board for its consideration.

In addition, as part of the departmental oversight work to progress the report's recommendations, the permanent secretary has established a weekly meeting to oversee oversight and accountability. It has representation from various groups and includes attendees from the Department, the SPPG, the Regulation and Quality Improvement Authority (RQIA) and the Patient and Client Council (PCC), as well as the chief executive of the Belfast Health and Social Care Trust. Independent members of the implementation oversight board have been invited to attend, should they wish to do so.

Regular updates will be provided to the Assembly and the Committee. When work has progressed sufficiently, it will be published on the departmental website. The format for that is being considered, but it is likely to be presented as a live dashboard, because that was a request from the families when the previous Minister met them. A dashboard was their preferred option.

In line with departmental guidance on responding to inquiries, however, a range of initial work will need to be completed before we are in a position to publish any updates. As part of that work, the Minister will need to set out a formal departmental response to the inquiry's recommendations.

I turn briefly to the Adult Protection Bill. The Committee will be aware that the report made a number of recommendations about the Bill, including recommendations on CCTV in care settings, adult safeguarding, the introduction of a statutory duty of candour and amendments to care offences in Part 3 to reflect the reverse burden of proof approach. That was referenced by the inquiry team when it launched its report, as was the need to put adult safeguarding on the same statutory footing as children's safeguarding. Given the potential implications for the Bill following the publication of the inquiry report, we have sought advice from the Office of the Legislative Counsel (OLC) on whether amendments are required to address a number of the report's recommendations. We have also sought further advice from the Departmental Solicitor's Office (DSO).

You will be aware, Chair, that the Committee Stage of the Adult Protection Bill ran until 27 March 2026. At the Committee's request, the previous Minister agreed to delay Consideration Stage in order to allow time for the inquiry report to be reviewed and to table any amendments to the Bill that might be required. We are keen to progress the Bill without further delay in order to support its passage in the current Assembly mandate and to deliver the statutory framework for the protection of adults envisaged in the Bill. A number of proposed departmental amendments that reflect engagement with a range of stakeholders, including the Committee, have been approved by the adult safeguarding transformation board and have been shared with the Committee. The development of the statutory guidance to accompany the Bill is also being progressed at pace by a dedicated project team overseen by the cross-departmental statutory working group. The Department intends to hold a full public consultation on the statutory guidance in order to encourage further input from interested parties.

Although we will need time to consider fully the inquiry's recommendations on CCTV, their implementation will not make CCTV mandatory in social care settings, and the inquiry report did not recommend that. The Committee will be aware that the transformation board considered the issue at length and agreed to recommend to the Executive that the Bill include a power enabling the Department to introduce regulations covering the use of CCTV. Again, the regulations will not make the use of CCTV mandatory, but they will enable the Department to set standards for its use.

The inquiry report also made a recommendation on a duty of candour. As part of the Department's commitment to fostering a culture of openness and transparency across the system, officials are working on introducing an organisational duty of candour Bill that would align Northern Ireland with the rest of the UK, where comparable statutory duties already help promote openness and honesty when things go wrong. It is intended that our Bill will go further than existing professional duties by placing a clear legal responsibility on organisations to act with honesty and transparency when things go wrong. The Bill will ensure that patients and their families receive timely, accurate and compassionate communication when harm occurs. The Minister is committed to seeing the legislation progress in this mandate. Although that will be challenging, officials continue to prepare a Bill for the Minister's consideration. At this time, the Department is also working closely with other Northern Ireland Departments to ensure that the UK's new Public Office (Accountability) Bill, often referred to as the "Hillsborough law", which creates an individual duty of candour for all public officials, will operate effectively here. Although its introduction is subject to Westminster time frames, we understand that that Bill will have completed its legislative passage towards the end of the 2026 calendar year, with implementation expected to commence across the UK by mid-2027. Taken together, the two Bills will represent a significant step forward in strengthening public trust, embedding a learning culture and delivering on the commitments set out in the HSC reset plan, as well as delivering against the recommendation in the Muckamore inquiry report.

Finally, I reassure the Committee that the new Minister is fully committed to implementing the inquiry report's recommendations and its learning as soon as possible. He is looking forward to meeting the families tomorrow to hear about their experiences and to listen to their views on how implementation should be progressed.

We are now happy to take questions.

The Chairperson (Mr McGuigan): Thank you very much for that, Mark. I will start by seeking to clear up exactly what the Department meant — this might have come not from you but from a spad in the Minister's private office — when it asked that, during this session, Committee members give some thought and sensitivity to the families who are meeting the Minister tomorrow.

Mr McGuicken: That was a misunderstanding on my part. I am not trying to put any blame on the private office. I had thought that this meeting would be more of an informal session, given that we are meeting the families tomorrow and that the Minister has not updated the Assembly on where we are.

I fully accept the blame for that, Chair. It was simply a misunderstanding on my part. There was no attempt to hide anything from the Committee about where we have got to with looking at the recommendations.

The Chairperson (Mr McGuigan): OK. Has there been slippage on the issue because we have a new Minister?

Mr McGuicken: No. The work has been going on at pace. We prepare a first-day brief and such things for a new Minister. There has been a slight pressure on resources, but, in working on the implementation structures, in discussing with trusts whether they are across all the detail of the recommendations and in preparing advice to the Minister, there has been no slippage. The change of Minister has not impacted at all on the Department's work on the recommendations; indeed, the Minister has brought Sean and me before him on a number of occasions since taking office to discuss where we are with them and to make sure that we continue to drive them forward at pace.

The Chairperson (Mr McGuigan): Minister Nesbitt gave a commitment to seeing progress made on the recommendations within six months; in fact, he went further than that, saying that progress would be seen well in advance of six months. We are now almost three months in. I accept what you say about meeting the families tomorrow and about the Minister making a statement to the House. We thought that that statement would be made last week. Are we still on schedule for families, the Committee and the public to see, well in advance of six months, considerable movement on implementing the recommendations?

Mr McGuicken: The new Minister wanted to meet the families before making any statement. Had the previous Minister still been in place —.

The Chairperson (Mr McGuigan): My question was about slippage, and you have identified where there has been slippage. Had the previous Minister still been in post, he would, in all likelihood, have made the statement last week, and, at this meeting, we would have been able to interrogate in greater detail some of the things that he had said.

Mr McGuicken: If you want to call that "slippage", Chair, I will not argue with you. That, however, has not impacted on our work on developing the proposals. The Minister was clear that he wanted to give the families their place before he made a statement to the Assembly.

There has been no slippage in our work on developing the proposals. We need to take the time to do this properly. The Minister wants to produce the formal response to the inquiry recommendations well before mid-December, so that is still our position. We are working towards that timescale. There has been no slippage on that.

The Chairperson (Mr McGuigan): OK. There is still a commitment to do that before mid-December.

Mr McGuicken: Absolutely.

The Chairperson (Mr McGuigan): A public dashboard was recommended. You have, thankfully, committed to that being the way in which families and the public — everybody — will be able to look at the changes as a result of implementation and judge them for themselves. When will the dashboard go live?

Mr McGuicken: At this stage, we have not developed what the public dashboard will look like. We have largely been focusing on looking at the recommendations, seeing where the system is and interrogating the recommendations where either they will have resource implications or we will need to determine exactly how they will work in practice. We have therefore not yet looked at the detail of what the dashboard will look like. We want to have a further conversation with the families — the meeting tomorrow is part of the ongoing process — to hear exactly what they would like to see. I do not envisage having a dashboard that states, "Here are 106 recommendations, and here are the minutiae of what we are doing on every recommendation". If, however, that is what the families want to see, that is what we will work towards.

We have grouped the recommendations into 10 work streams and are looking to put in place a structure for those 10 work streams, which will be chaired at senior levels in the system. We will probably receive a report on each work stream. That might be what we publish. One work stream will be responsible for delivering on one recommendation on redress, while other work streams will be responsible for delivering on between nine and 22 recommendations. We therefore need to have a process that provides the information that the Committee, the public and the families want without overburdening the system in a way that means that all that it does is report against a delivery mechanism rather than get on with making the difference that the recommendations need to make.

To answer your question succinctly, Chair, we do not yet know what the dashboard will look like. We want to engage further with the families to make sure that what we propose is exactly what they require.

The Chairperson (Mr McGuigan): Fair enough. I have three questions, which I will ask reasonably quickly. The first is similar to one that I asked the Belfast Trust earlier. We met Tom Kark from the inquiry panel and had a good conversation with him. I cannot speak for the rest of the Committee, but, after I asked him about the engagement that there has been since between the Department and the panel, given the panel's work and the recommendations that it produced and given the seriousness of the issue, I was shocked to hear him say that there had been no engagement. As I said, I asked the Belfast Trust a similar question. I am aghast. I cannot understand how, given the gravity of the inquiry and the issue involved and the fact that the inquiry panel produced a report with 106 recommendations — I accept that not all of them are for the Department of Health, but the majority are — absolutely no conversation has taken place in the three months since, involving questions as simple as, "What did you mean by this recommendation?", "What are the implications of this recommendation?" and, "Here's what we're thinking. If we did that, would that satisfy your recommendations?". I just cannot figure out why such conversations have not taken place.

Mr McGuicken: The Minister is due to meet Tom next week. I will be at that meeting with him.

The Chairperson (Mr McGuigan): Three months after.

Mr McGuicken: The Minister is due to meet him next week, Chair. We are open to having a dialogue back and forth, if the chair of the panel wishes to do so.

The Chairperson (Mr McGuigan): You say now that you are open to having that dialogue, but my point is that nothing has happened in three months.

Mr McGuicken: We have been looking at the 106 recommendations. For the most part, they are relatively clear in their intent, and we are relatively clear about what the inquiry panel has asked us to do in order to deliver on them. There will be some recommendations about which we think, "What does that mean?" and, "How do we implement this?". When the Department gets to the point of responding to the recommendations, we will have to have a discussion about implementation with the chair of the inquiry panel. As I said, we are more than willing to have a conversation with him about the recommendations that require further discussion, if he is open to doing so.

The Chairperson (Mr McGuigan): I am not convinced by that. You said that you intend to work up to a certain point and then have that conversation. What happens if you work for four months and then have the conversation with the inquiry panel, and it says, "That isn't what we wanted you to do in the first instance. That's not what we envisaged"? Perhaps I am being simplistic, but I would have thought it important to have a conversation before the work started in order for the Department to ask, "What do you envisage us coming up with for this recommendation?".

Mr McGuicken: We have taken the approach of looking at what we are doing, looking at the recommendations and looking at what is being done in each of the trusts in order to work out exactly where the pinch points, for want of a better term, are for the recommendations on which, we believe, further engagement with the inquiry panel would be helpful. I take your point totally, Chair, that it has been three months, but it is not as though we have been sitting on our hands for all that time and not trying to start the work on implementation. At this stage, we have not felt the need to go to the inquiry panel or its chair to ask, "Exactly what do you mean by that?", but we are open to doing so. I take your point, Chair, but, had we felt the need to go to the inquiry panel chair before now, I have no doubt that we would have done so. I am sure that, having worked with him throughout the inquiry, Tom would have been open to our going to him.

The Chairperson (Mr McGuigan): He was very open to that; that is my point. My questions come on the back of a conversation that Tom and the Committee had. He was probably as shocked and surprised as we were that there had been no engagement.

I will move on to the duty of candour. We will not have time to get into organisational and individual duty of candour today; that is a conversation that we will, no doubt, have in the Chamber. Minister Nesbitt gave a commitment that legislation on a duty of candour would be produced for the Committee and others to scrutinise. We are now less than seven months away from purdah. The Committee intends to do its duty and scrutinise properly that major piece of legislation, but we are running out of time for that to happen. The Minister gave a commitment, so when will we see legislation on a duty of candour?

Mr McGuicken: That does not sit within my remit, but I understand that a paper on a duty of candour Bill is being prepared as we speak, and it will go to the Executive for consideration. Apologies, Chair, but I do not have the level of detail that you seek.

The Chairperson (Mr McGuigan): It is one of the report's recommendations.

Mr McGuicken: It is, yes, and, as part of the structure that we have developed, duty of candour will be a work stream in its own right. The work that Patricia Donnelly did, which I mentioned earlier, looked at the recommendations of this inquiry and mapped them against the recommendations from other inquiries. The only recommendation that, in its entirety, could fit elsewhere was that on the duty of candour. Although every other one of the 105 recommendations had strong linkages to other inquiries, the recommendation on a duty of candour was the only one on which we could say, "We can lift that recommendation. The work is already being done, so it can be carried forward by the team that is looking at a duty of candour". As I said, my understanding is that that is with the Minister for consideration, but I do not know the exact timescale.

The Chairperson (Mr McGuigan): I will finish on this. I think that it was Danny who asked Jennifer Welsh, the chief executive of Belfast Trust, about potential further inquiries, and she said that it is shameful that we have had the need for so many inquiries. In my view, duty of candour legislation is key to ensuring that we do not have future inquiries. It is absolutely essential.

Mr McGuicken: My understanding is that the Minister is fully committed to having an organisational duty of candour and an individual duty of candour. As I said, I understand that that would take us further than other parts of the UK with such legislation.

The Chairperson (Mr McGuigan): I will move on. I had more questions, but we are running out of time.

Miss McAllister: Thank you very much for coming to the Committee today. I had similar questions on the duty of candour, but I will perhaps pivot to the recommendations.

Mark, you said that a number of the recommendations will require legislation. Separate from that, the chair of the inquiry panel outlined how the Adult Protection Bill might be enhanced and strengthened. Aside from the duty of candour, what recommendations require legislation that will not be able to be included in amendments to the Adult Protection Bill? As we know, legislation moves slowly. Which of the policy changes from the recommendations that will require legislation will not fit into the Adult Protection Bill?

Mr McGuicken: I will give you one example, Nuala. Apologies, but I cannot remember which number the recommendation is. It is the one that recommends having protected time for discussions and for consultations on, I think, care plans. Allowing protected time for such discussions could have an impact on what we are doing on safer staffing levels. There are other things that might have a legislative impact —.

Miss McAllister: Do you mean that that might have an impact on the safer staffing legislation?

Mr McGuicken: It will potentially have an impact on how we deliver the specific recommendation of having protected time. Another recommendation that may require legislative change is the recommendation on the role of non-executive directors.

Miss McAllister: Would that be Department of Health legislation or Department of Finance legislation, or is it all Health legislation?

Mr McGuicken: To take a step back, we have looked at the recommendations in the round and asked whether we believe that they can be implemented, whether we accept them in full, whether we accept them in principle and whether there are any that, we will advise the Minister, we will probably not accept. We are having a conversation about that last category, but it is highly unlikely that we will say to the Minister that we do not accept any of the recommendations.

We grouped the recommendations into the 10 work streams that we have established, and it will be up to each work stream to look at them in detail and say what the implications are for delivering on the recommendations, whether those are legislative implications or financial implications and how the recommendations will be delivered on across the trusts and for the third-party providers for the supported living environment in which a lot of the individuals from Muckamore now reside.

The level of detail on what legislation a recommendation will impact on and how we will deliver on it is part of the process of establishing those work streams for the relevant managers to take forward the recommendations. At this stage, I do not have the detail on the exact legislation that will be required, but our analysis has shown that there may be implications for legislation from a number of the recommendations.

Mr Sean Scullion (Department of Health): We will develop an assurance framework for each work stream, Nuala. Those assurance frameworks will be the place in which we will set that out. As part of their work, the work streams will look at

and at any potential legislative impacts and any resource impacts.

Miss McAllister: The trust said previously that it reports to the Department on the implementation of its new governance structure, with a group overseeing that. I ask that the Department include in its updates to the Committee what has been implemented and what has not and what the impacts are on legislation. As soon as I heard what you said, I thought, "Years". We know that legislation takes time, so it will be years. It would be helpful if we were aware of whether, as well as a policy change, legislation is required or whether the policy can be implemented without the need for legislation.

Mr McGuicken: We may be able to do something through policy to reflect the spirit of the recommendations, but legislative change may then be required. Some of that may be able to be done through secondary legislation, while some of it may require primary legislation. The timescales will depend on what changes are required, Nuala.

Miss McAllister: Let us hope that we see something.

Mr McGuicken: We are clear, however, that, where we can implement something now that will require a legislative change further down the line, that will be the direction that we will follow.

Miss McAllister: Sean, are you the responsible lead in the Department for the governance structure that oversees the trusts' implementation of the recommendations?

Mr Scullion: The scoping work that we are doing at the minute will develop a governance structure, and that is in line with the Department's guidance on responding to healthcare inquiries. That is important, because it sets out the arrangements for oversight of the implementation of the recommendations so that we can demonstrate evidence that things are happening and that things are changing. We are in the process of developing a proposed governance structure. Some of the recommendations set out specific requirements for what the governance structure should include. For example, R1 states:

That group will form part of our governance arrangements. We are clear that we want to engage with families and service users on how they need to be involved and on what the implementation consultation group should look like. At this stage, we have a proposed governance structure, but we have not engaged with families on it or shared it more widely. We want to do that before we put any firm advice to the Minister.

Mr McGuicken: Sorry to interrupt. We have also engaged extensively with the PCC about what the engagement structure might look like. We have run it past one of the independent members of the inquiries implementation oversight board, whose specific remit is to do with engagement, to see whether it looks right. We then want to have a conversation with the families and service users to ask them whether that is how they envisage being engaged as part of the process. We do not want to come at it with a predetermined approach to engage in only one way; we want to make sure that engagement is sufficient for the families to ensure that we can show them that progress is being made and that we are implementing the recommendations as envisaged by the report.

As I said, we are putting advice to the Minister. Tomorrow's meeting will hopefully flesh out a bit more where we go when it comes to engagement with the families. Equally, however, we do not want to place undue pressure on the group of families to retell their stories continually. We want to get to a point at which we have a structure in place that shows that we have committed to how families want to be engaged with. As I said, there is work being done with the PCC and even with organisations such as the Association for Real Change in Northern Ireland (ARC NI), which has a good footprint of service-user engagement, to determine how we engage with service users, families and patients. We believe that the structure will deliver the governance that we require, but we need to make sure that it also delivers the engagement that the families want.

Miss McAllister: Thank you. That leads me on to my next point, which is about engagement with the families. We have just discussed that with the Belfast Trust, which raised with us the issue of instances when there is no agreement between families and the trust about what is in best interests of the service user or no agreement on future planning. Can the Department provide an assurance that it will monitor that? We talked about how attitudes and culture in the trust have not changed. We get updates and attend meetings for over-18s and under-18s, and the way in which families are spoken to is not nice. That often leads to a breakdown of relationships and differences in agreement. Can the governance structure also monitor cases in which there has been no agreement between the family and the trust about the future of the individual?

Can we have some assurance from the Department that that will also be examined?

Mr McGuicken: I do not think that, as part of the implementation of these recommendations, we will get into individual issues around placements or treatment for individual service users or patients. That is an issue that needs to be monitored at trust level. We have a governance framework and an escalation framework, which Ciara might say a bit more about. However, the delivery of the recommendations will be about systemic changes rather than individual conversations about individual patients or circumstances in a particular setting. To give an assurance that the structure would look at that would misrepresent what we are trying to do with regard to the implementation of the recommendations.

Miss McAllister: I understand that, but there is a balance of power and where the power lies between the state and an individual. When someone does not have capacity, the state has the power and will often use that in a way that suits it. It may put something forward as the best interest, but there is a perception from families that I have witnessed myself. It might not be individual cases; it is the use of the tools of the trusts and the state to override the wishes of families. That needs to be monitored in some way. It might not involve the individual details of each family. There was something in the media last week; it was mostly under-18s. What happened there was a nasty weapon used on families. It needs to be monitored to some degree.

Mr Scullion: A clear message from the inquiry's recommendations was the importance of engaging with families as partners in planning and delivering their care. There are specific operational recommendations that should improve that. Those will be monitored as part of the overall governance structure.

Dr Ciara McKillop (Department of Health): There are quite a number of recommendations in the report around care planning, which is the essence of what you are doing: who is involved in writing a care plan; who is engaging in a care plan; who is overseeing a care plan; how a care plan is jointly owned; and the status of a care plan. For example, if elements of a care plan cannot be implemented or if there is a dispute, that is recorded formally on the trust's governance system as a miscare episode, which does not happen immediately. We have engaged with all the trusts about their view of that. They have accepted every one of the recommendations around care planning and inpatient care. We are at the stage of trying to identify the mechanics of how we ensure that that is done consistently and regionally. We are at the stage of thinking about second-line assurance. If the trusts say that they can stand over that and that everybody has access to a care plan, how do we get second-line assurance of that? Our discussions with RQIA are about making sure that the trusts say yes, but we have a mechanism for the ongoing assurance of that down the line.

Some of the recommendations are straightforward to implement, such as ensuring that everybody has access to a care plan. Some of the recommendations falling within that around human rights compliance, which you were talking about, were very strong in the report. They will take a bit more unpacking and understanding. We have begun to do our homework on some of those. They are likely to be the small number of recommendations that we will take back to the inquiry to clarify whether our understanding of what it is talking about is similar to its understanding, such as the recommendation around the role of human rights officers across services.

Mr McGuicken: We also want to be really clear that there is consistent implementation across all trusts. One of the pivotal roles will be to ensure that oversight arrangements are delivered consistently across all trusts. The focus has been on Belfast and what happened in Muckamore, but it is much wider going forward.

Mr Donnelly: A couple of the questions that I was going to ask have been asked, but I want to develop a couple of them. Representatives from the trust were here earlier, and I asked them about their ownership of the recommendations and which ones they had accepted responsibility for. You highlighted that recommendation 88 is for the PSNI and recommendation 89 is for the Department of Justice. Out of the full 106 recommendations, is there any dispute between you and the trust or any other organisation about ownership and responsibility for any of them?

Dr McKillop: There have been no disputes, but some have been ascribed to the trusts that sit better with the RQIA. There has been no dispute at all.

Mr McGuicken: It is important to note the breakdown of the recommendations: 63 for trusts; 42 for private sector and care providers; 34 for the Department and SPPG; eight for the RQIA; four for PCC; two for PHA; two for the Clinical Education Centre (CEC); two for the leadership centre; one for the Northern Ireland Practice and Education Council for Nursing and Midwifery; one for local commissioning groups; one for PSNI; one for DOJ; one for the Housing Executive; and one for DFC. There is significant overlap between them. From my perspective, one of the most challenging things will be delivering some of the recommendations where there is a cutover between what trusts deliver and what independent sector providers deliver.

With regard to the 42 recommendations for private and third-sector providers, they are not one homogenous group of people that we deal with from one base; we will have to engage directly with all those organisations to see how that will work. That is where we envisage the work stream leads taking those forward to say, "This is how it is working in the trust. How do we make sure that is right, and how do we make sure that, once somebody is resettled or discharged from a hospital setting, the same thing is implemented?".

Ciara mentioned human rights officers. One of the recommendations is that each organisation will have a human rights officer. We need to work out what that looks like and what that means. Another recommendation — I paraphrase — is that any setting that has an individual with challenging behaviours is automatically put on the risk register of the trust. That is really difficult when some of those settings will be in a third-party organisation. That is one where we will have to have a conversation with the chair and the panel to ask what they envisage by that. There will be some that will be challenging. Again, that might bring in some legislative change, but we can do it by policy in the first instance.

Mr Donnelly: Are you planning to start those conversations with the chair and the panel soon?

Mr McGuicken: Next week.

Mr Donnelly: You mentioned duty of candour: from what you said, the plan is that the duty of candour Bill will come forward in this mandate.

Mr McGuicken: That is my understanding, Danny, but it sits outside the remit of what I am delivering.

Mr Donnelly: But you still want to — the recommendations —.

Mr McGuicken: Yes.

Mr Donnelly: You also mentioned implications for safe staffing: is the safe staffing Bill coming forward? Can you tell us anything about that?

Mr McGuicken: I will have to come back to you on that. It is not within my remit. I do not know, but we will write to the Committee on that.

Mr Donnelly: The issue of redress was raised in the inquiry report: have there been any conversations with families about redress?

Mr McGuicken: We have not had any conversations with families at this point. We have drafted a proposal that will hopefully go to the Minister this week. We wanted to have a conversation with colleagues in TEO around the mother-and-baby homes redress scheme and how it had gone forward with that. We were only able to have that conversation on Friday, and that has developed some of our thinking about what that approach might look like. There are some clear points about where families would be engaged as part of that. If you are setting up a statutory scheme for the delivery of that, it would not be for families to be part of that structure. The recommendation commits us to set up a small working group to look at that. We envisage potentially setting up an independent panel that will engage with families about what that would look like to bring back recommendations to the Minister and the Department. We have developed a submission to the Minister, which, hopefully, will go to him this week, based on our discussions with TEO colleagues last Friday.

Mr Donnelly: Lastly, independent advocates were mentioned in the report and in the progression of the Adult Protection Bill: have there been any discussions in the Department about recruiting and resourcing them?

Mr McGuicken: Not at this point. The working group will take that forward and bring recommendations through into the implementation oversight group about how that will be delivered. There have been no specific conversations about that, other than the conversations that we had previously on the Adult Protection Bill.

Mrs Dillon: You will be glad to hear that most of my questions have been covered. I will go back to a point that I raised with the trust about how you ensure that families are properly listened to. That is across the board, not just in relation to Muckamore. For example, all young people with challenges, learning disabilities or autism and their families are potentially not being listened to. We have seen in other trusts that young people with challenging behaviours and their families are not listened to. How do we ensure that families are given genuinely equal hearing and are not told, "We all know better" all the time? I say that as somebody who has to implement policy and legislation. None of us should do that without genuinely listening to families.

There are ways, and families will help us to do it. For example, Caleb's Cause is doing a survey at the minute. Obviously, you have to stand over anything that you implement and any research that you do, but there is no harm in looking at that. There is no harm in asking, "What responses are coming in? Is there something we should be doing differently? Are the policies that we have in place right? Are they being implemented correctly, or should we go away and look at how we do things?". Even with these recommendations, we will do things and then need to go back to look at them and say, "You know, it was a good recommendation in its time, but now, with all of this other stuff, is it the right one? Is it being implemented correctly? Are we working through it correctly?". You might implement the recommendation, but what are you doing at the end of it?

As I said to the trust, it is about institutional memory. We all know about Muckamore, so we are all in a panic to make sure that everything is right in the future, but, in 10 years' time, the people in our positions will not know about Muckamore. They will have heard about it, but they will not have lived through the experience. I just worry that we allow the same things to repeat because people forget. How do we make sure that that does not happen? For me, that is the culture change. I said that to the trust. It is for its staff, but it is also for the Department and for us as elected representatives. We all need to make sure that we listen when people who know better — the families of those people — tell us that things are not right.

Mr McGuicken: The previous structure that we had — the Muckamore departmental assurance group — had family representation on it, largely to keep us right, Linda, in delivering that. We want to engage with families to say, "What is the best way for us to engage in this? Do you want us to engage in an individual, recommendation-by-recommendation process?". With some recommendations, we just need to get on and do it, make sure that families understand what we are doing and make sure that what we do is right when it comes to delivery. With other recommendations, we will ask the family, "What do you believe that this means? What do you want us to do on this?". At the top, the implementation group will also have family representation on it to keep the system right when it comes to delivery. That group will report to the implementation programme management board, which, again, has independent members to make sure that that is done.

The PCC has developed a five-step process of what engagement might look like. As I said, we have run that by Brian O'Hagan, who sits on the independent implementation monitoring board, to ask whether it looks like the right approach. Tomorrow's conversation with the families will start to flesh out that process slightly more. However, you are right, Linda. I suggest that we are not panicking about delivering this. We want to do it right, and the time that we are taking to do it is right and proper in order to establish the structures to deliver it properly, but I understand the sentiment of what you said. We need to make sure that we —.

Mrs Dillon: It is about the other side of it.

Mr McGuicken: It is, yes.

Mrs Dillon: I accept that families are being engaged with, and that is really important, because they need to understand the process and you need to understand what they expect to get from it, but it is about the other side of it: the outcomes. Will they feel the difference on the ground? With the best will in the world, there will still be problems and challenges. How do we ensure that, when they come with something in the future, they will feel that the culture has changed so that when they say, "Listen, I know that you have implemented this, but here's the craic: it is not working for my young person. Here is what is happening", they genuinely believe that they are being listened to and are not told, "We have done this; we have done that; we have put this in place; we have this policy; we have that governance", but told, "OK. You are telling us that something is wrong here. How do we get the reassurance that it is not and give you that reassurance?" and then are listened to if they come back and say, "It is still not right"?

Mr McGuicken: It is not just about engagement but about involvement. Families, service users and those with lived experience need to feel absolutely 100% part of the process. We need to get the structures right through our work with the PCC, Arc and others to make sure that all the voices are heard as part of the conversation. However, you are right: I firmly believe that the families will hold us to account as part of the process to make sure we deliver the structures, and we welcome that. We have had that from the Muckamore departmental assurance group to date and the family members who have engaged with us as part of that process. We are also doing a piece of work with the RQIA and the Royal College of Psychiatrists about what betterment looks like. We are looking at a number of resettlements from Muckamore to make sure that the resettlement process has provided betterment for those individuals. It is not just a matter of resettling from hospital and nothing changes; it is about making sure that what we do for those individuals makes their lives better and more fulfilled. It is not just about talking to families about the process — you are right about the difference that it makes — but about having those conversations with the individuals who have been resettled, where they have capacity, to ask, "What is your life like now? Has what you expected been fulfilled in terms of what the resettlement process has been?". Learning will come back from that as well, Linda.

We are not just looking at the 106 recommendations and saying, "That is it". There are other processes, including the learning disability service model — we will not get into that today — and it will be about changing the processes and what we provide by way of a service. Again, that has been built up by significant engagement with the families, service users and the wider system. We are listening, and we are making sure that the family voices are heard. If it was not for the family voices, we would not be here, and we all know that. Therefore, it is important that, when those families raise those issues — it is similar to what Nuala was saying — they are listened to and the system respects those voices. At the end of the day, their loved ones are the ultimate end users of the service we provide, and it is essential that that engagement and involvement is pivotal and central to the process.

Mrs Dillon: I will make the point again as my final point. The work with the Royal College of Psychiatrists is good, but I have worked with families who felt that the young person or adult was being over-medicated, and they were right. The medication was not correctly monitored, and that was done by psychiatrists. You have to understand that the families are coming from the point of view that they did not always have the best experience, and I say that with the greatest respect to everybody who does a good job, but not everybody did a good job.

Mr McGuicken: That is understood.

Mrs Dillon: Those families very much felt that they were not listened to, and it went back to that, "I know better. We know better". It is important to listen to people about whether their experience is better and they are living a better life. The families will know when they go to see them because they will be happier; they will be in better form; they will be more settled; and their physical health will improve. Everything will be better, and the people who love them and have looked after them like a wee egg for as long as they could will know if something is not right.

Mr McGuicken: The Belfast Trust is going through a process of direct engagement with the families who want to have those conversations. To be fair to Jennifer and Stuart, they are engaging directly with those families, and we need to learn. Nobody is hiding behind the fact that we need to learn.

Mrs Dillon: Thank you.

Mr Robinson: Mark, given that the duty of candour piece now requires a work stream, are you confident that that will not slow progress?

Mr McGuicken: We are saying that, as part of looking at the 106 recommendations, the duty of candour is work stream 10. We will not do anything new on that. Apologies if I misled you, Alan. The recommendation on the duty of candour will go directly to the people who are working on the duty of candour. It is the only one that we can lift and put somewhere else where work is already ongoing.

Mr Robinson: I understand, and that clarifies it.

Who will be responsible for running the dashboard? Is there a cost to date that you envisage?

Mr McGuicken: There will be cost implications for quite a few of the recommendations, but, as I explained, we have not yet gone into that level of detail. The responsibility for publishing what is ongoing will ultimately be held by the Department as part of the updates, but they will go to the implementation oversight group, and family members and others will be on that. It will be overseen by that group, but it will be populated by the Department, and it is envisaged as a public-facing dashboard, if that is what the families believe to be the best way forward.

Mr Robinson: OK.

Mr Donnelly: Earlier, we heard from the trust about the adversarial stance that it had taken during the inquiry. The Department has oversight over the trusts: what is your opinion on that? Did you have any oversight of how the trust was involved in the inquiry at the time?

Mr McGuicken: The trust was a core participant in its own right in the same way as the Department was a core participant in its own right. We had our own legal team. We used the Departmental Solicitor's Office. The trust used the Directorate of Legal Services (DLS). They are two totally separate legal entities. Due to the construct of the trust, it uses DLS and we, as the Department, use DSO. The way it engaged was a matter for the trust directly.

The previous Minister had a discussion with Jennifer and Stuart directly after the publication of the report and made his views clear about the inquiry's suggestion of an adversarial approach. He made his views very clear. However, we did not have any oversight of or input into how the trust responded to the inquiry because it was a core participant in its own right in the same way as RQIA and PHA were core participants. The Department was a core participant and was totally separate. For example, we did not see the warning letter that went to the Belfast Trust. We did not see the response that went in. We got our own warning letter, and we responded to it in our way. There was total division between each core participant. We did not have input into its statements, and it did not have input into our statements. It was totally separate, Danny.

Mr Donnelly: Concerns were raised about the trust's inability to change its culture: does that concern you as the Department?

Mr McGuicken: The previous Minister was clear at the quality and improvement summit shortly afterwards about his expectations of change and the expectation of all senior leaders in the organisations to change. The previous Minister was also clear about his conversations with the chair and the chief executive about the need for change. It is probably not for me to form an opinion on whether the trust can change. From my engagement with the trust, the chief executive and Peter Sloan, who was here, I believe that they are fully wedded to delivering that in conjunction with us as the Department and as a partner in delivering that going forward. I have no difficulty with the engagement that the trust has had with us — not just the Belfast Trust, but all the trusts and all the directors of learning disability — and their commitment to driving this forward and ensuring that we deliver the recommendations.

Dr McKillop: I will echo that. We met trusts' directors of learning disability the week that the inquiry report came out, including the director from the Belfast Trust. They submitted a return about the state of the nation with regard to where they were on all the recommendations. We have met them at least monthly since, if not more frequently than that, to begin to work through that structure and the progress that we need to see. We have had absolutely no issues. The attitude is, "How do we do this? How do we change the system? How do we ensure that is sustainable?"; it is not, "Should we?" or "Could we?". It is not that; it is, "How do we?". There has been no pushback at all.

Mr Donnelly: That is reassuring to hear. Thank you.

Dr McKillop: The inquiry has been taken so very seriously. The need for change and for the health service and social care service to be different going forward is completely accepted. It is a shame on us all that this happened in our health and social care system. There is an absolute determination that it will be different going forward.

Mr McGuicken: To be fair to the trusts, we are probably telling them, "You need to step back slightly, as opposed to running off and doing this on your own", because there is a desire to hit the ground running and get on with it. We are trying to say, "We need this to be a structure where we can say that it is being delivered regionally across all trusts with consistency", and to put the governance structures in place and do the initial response to the inquiry. Earlier, the Chair asked about whether the change of Minister had impacted that: it has not. We just want to get this right and take a bit of time to ensure that what we do is the proper structure and the proper process going forward, as Sean said, taking account of the governance around all inquiries about how we deliver that.

There has been absolutely no pushback from the trusts. Nobody underestimates the task. We all appreciate that this is huge in terms of delivering this and the system change. However, there has been no pushback saying, "We do not want to". It is about , "How do we do this and how do we ensure that we do it right?".

Dr McKillop: It will not be a tick-box exercise. PCC talks a lot about ensuring that we achieve the systemic change going forward. That is our intention. This is not about us running down 106 recommendations and crossing them off.

Mr McGuicken: I suppose that it is also important to say — I should have said it at the start — that, while this is focused on learning disability, just because we do something in learning disability, why should we not replicate it in mental health or older people's services? The initial focus will be on delivering this in the learning disability service and how we make it better. Then it will be about how we replicate that elsewhere. Just because everybody has access to a care plan for somebody with a learning disability, why should that not happen across all the other areas? It is about ensuring that there is system change not just for this but for the wider system. Again, we need to take the process step by step to make sure that we do it right.

The Chairperson (Mr McGuigan): I need to cut in there. There are two equally important issues: implementing the recommendations on Muckamore and getting the Adult Protection Bill correct. Refresh my memory: you are looking at that and taking legal advice. When do you suspect you will be in a position to suggest amendments?

Mr McGuicken: We sought legal advice from OLC, which was comprehensive, as it has always been from colleagues in OLC. We put that to DSO. We have another Adult Protection Board meeting next Thursday, where we hope to get agreement on the way forward. We are still discussing other potential amendments, Chair. I would like us to be in a position to get advice to the Minister in very early October, which would allow us to bring it back to you then, if not before that.

We are still pushing to get the Adult Protection Bill through in this mandate. That is our clear objective. At this stage, we do not see wholesale substantive changes, if any, to the Bill as an outworking of the inquiry's recommendations. A lot of the recommendations around CCTV will be dealt with in secondary legislation, as opposed to making changes to the substantive Bill. There is just a bit of working out to be done on the reverse burden recommendation. That is the one that we are taking advice on from OLC and DSO.

The Chairperson (Mr McGuigan): Thank you all very much for coming before us today. I appreciate that.