
	National Assembly for Wales Finance Committee
Purpose:	The Welsh NHS Confederation’s response to the inquiry into the consideration of powers of the Public Services Ombudsman for Wales
Contact:	Nesta Lloyd – Jones, Policy and Public Affairs Officer, Welsh NHS Confederation Nesta.lloyd-jones@welshconfed.org Tel: 02920 349857
Date created:	19 March 2015

Introduction

1. The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to respond to the Finance Committee’s inquiry into the consideration of powers of the Public Services Ombudsman for Wales (PSOW).

2. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

3. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members’ involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.

4. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

Summary

5. Patients’ expectations of the NHS are growing. It is not only about whether their treatment worked or how long they had to wait, but how they were cared for by staff, how they were spoken to and how comfortable they were made to feel. Quality of care in all its forms is a critical issue for healthcare providers and something that the NHS must get right.

6. Patients in Wales come into contact with the NHS more than 22 million times each year. A recent survey showed that 94% of patients were satisfied with the overall care they received and 97% of patients in Wales say they were treated with dignity and respect when using hospital services.^{^[i]} However, as Keith Evans’ review[ii] into NHS complaints recently highlighted, there is always room for improvement and there is no doubt that there are areas where more can be done. Local Health Boards (LHBs) and NHS Trusts are doing more and more to encourage feedback from patients, their families and their carers to make sure they are getting these things right, and treating patients and their families in the way they should expect; with dignity, compassion and respect.

7. Effective investigative processes and feedback and complaints systems are an integral part of an open and transparent culture in the NHS. The complaints process within the NHS has become more accessible and complaints should be, and generally are, seen by the NHS in Wales as an opportunity to improve services. The PSOW is a key part of this, and provides an effective escalating route for complaints. It is independent of the service which is important to ensure public confidence in the NHS.

Consultation Questions

Q1. What are your views on the effectiveness of the current Public Services Ombudsman (Wales) Act 2005?

8. The PSOW provides an effective escalation route for complainants and is the final tier in the complaints system in Wales. The PSOW is independent of the services in their jurisdiction and uses an investigative rather than adversarial approach. It is free to use and is an objective arbiter of complaints. It has a dual role - investigating complaints and improving services – and therefore provides a fair and unbiased arena for complainants.

9. Presently there are some limitations with the current powers within the Public Services Ombudsman (Wales) Act 2005. The current powers prevent some of the population from making a complaint, or for the PSOW to operate in the most effective manner, for example in relation to private care. The Act needs to be updated to reflect modern society and the nature of modern public services in Wales.

10. It is difficult to evidence clearly the effectiveness of the PSOW. The objectives of the PSOW are to ensure an absence of maladministration during the complaints process and in decision making. The focus of the office is therefore upon process not outcome. The result may be dissatisfied stakeholders who may be subject to fair process however may not think the outcome is fair and cannot appeal the findings. In addition, it is unclear how the PSOW evaluates its performance and effectiveness - would a reduction in individual complaints be a sign of success? We recommend that the PSOW should consider appropriate measures of success and not just rely on monitoring numbers and analysis of cases from each NHS body / public service organisation.

Own initiative investigations

Q2. Currently, the Ombudsman may only investigate a matter that is the subject of a complaint made to him/her. What are your views on “own initiative‟ investigations powers, which would enable the Ombudsman to initiate his/her own investigations without having first received a complaint about an issue. Please explain your answer.

11. The Welsh NHS Confederation recommends that the PSOW should be able to undertake “own initiative” investigations where there is firm evidence of widespread maladministration or service failure affecting the population. In addition other organisations, such as Healthcare Inspectorate Wales (HIW), have the authority to undertake own initiative investigations.

12. While the PSOW is ideally placed to pick up issues both within organisations and across Wales and bring an independent view to the concerns, the NHS in Wales would be concerned about the introduction of “own initiative” investigations by the PSOW, unless there is firm evidence, as this would be a significant retraction from their prime purpose and remit as a complaints arbitrator. In addition, given the existing roles of the regulatory bodies whose activities impact upon the activities of the NHS bodies in Wales, we feel that the addition of such “own initiative” investigations by the PSOW would represent a duplication of activities between such bodies. It will be essential that this does not lead to repetitive inspection and investigation where there are already inspection or regulatory bodies in place, for example HIW. Careful consideration of the role of other regulators/ inspectorate bodies, such as HIW and Community Health Councils, are required and there will need to be explicit pathways in place to ensure that where relevant intelligence is passed to an alternative body for investigation the PSOW is made aware of this, and vice versa.

13. In addition, while “own initiative” investigation powers may seem an appropriate addition, there are potential implications for the NHS in Wales. The PSOW could choose to investigate a specific issue where there are no specific themes for the PSOW to investigate, for example the proposed changes could allow the PSOW to investigate the failings of the Welsh Ambulance Service NHS Trust to meet the ambulance response times in a specific area or service redesign in another area. PSOW currently imposes financial penalties in regards to maladministration which are subjective - would service failings also result in penalties? There is a risk that the PSOW could end up with an agenda that is not in the best interests of the public.

14. Finally, in order to fully respond to this question there needs to be further explanation of this power. We note that in the Republic of Ireland only 5 such reviews were undertaken between 2001 and 2010. Clarification is required as to the triggers for these powers to be used. Furthermore there is need for careful consideration of the role of other regulatory/ inspectorate bodies such as HIW and Community Health Councils and the need for sharing of intelligence to ensure that the most appropriate body undertakes the review.

Q3. Do you have any concerns that own - initiative investigation powers could result in the Ombudsman’s responsibilities overlapping with the responsibilities of other bodies? How could this be managed?

15. As highlighted previously, there is a significant risk of PSOW responsibilities overlapping with the responsibilities of other bodies. NHS bodies across Wales are accountable to the Welsh Government’s Healthcare Quality Division in relation to service failing and subsequent Serious Adverse Incidents investigations. There may also be overlapping in regards to the responsibility and purpose of HIW. HIW provides assurances on the quality, safety and effectiveness of healthcare services and they also make recommendations to healthcare organisations to promote improvements.

16. The Welsh NHS Confederation believes it would be more appropriate that where the PSOW identifies generic issues which require investigation, following the provision of clear evidence and a rationale to why there should be such an investigation, he/ she should link into the existing bodies who are resourced and experienced in undertaking such investigations. This approach would avoid duplication of activities, prevent placing unreasonable burdens on NHS bodies, and improve the utilisation of limited resources. It would ensure that any investigation being undertaken would reflect and consider the intelligence and main issues of the relevant NHS body.

17. The Welsh NHS Confederation recommends if any “own initiative” investigations were being considered, there would need to be an early dialogue between the PSOW office, the NHS service and Welsh Government/HIW and other investigative bodies.

Q4. Do you have a view on the likely financial costs and benefits of the Ombudsman having “own-initiative” powers?

18. The costs and benefits are difficult to quantify without full understanding of the powers sought. The scale and scope of “own initiative” investigations have the potential to be far more comprehensive than those currently undertaken through the 2005 Act. This therefore has the potential for such investigations to be lengthy and costly. Factors that might introduce costs could include:

a) PSOW’s staffing: There will be a cost implication in regard to staffing depending on how many investigations PSOW would undertake each year. It could require additional PSOW staff to accommodate the additional investigations.

b) Cost to the NHS in Wales: There would also be a financial cost to the NHS in Wales in relation to the additional time spent on undertaking investigations. The NHS in Wales is currently obliged to support timely investigations and these additional powers could increase the amount of information that will be asked of NHS bodies.

19. While there are financial implications the benefits might include earlier recognition of pan-Wales issues which could help reduce claims. However the NHS in Wales does already have clear bodies in place to audit and consider system-wide issues.

20. The Welsh NHS Confederation recommends that a cost-benefit analysis will need to be undertaken as part of the decision making process. Given the work of the existing bodies in this area it is likely that the cost benefits would be disproportionate.

Oral Complaints

Q5. At present, the Ombudsman can only accept complaints in writing. What are your views on the Ombudsman being able to accept complaints made orally? Please explain your answer.

21. The Welsh NHS Confederation recommends that the PSOW should accept complaints in whichever format best suits the complainant, including through the medium of Welsh. It is very important that the investigative powers of the PSOW are accessible to all.

22. Only accepting complaints in writing may inhibit or prevent some members of the public from pursuing a complaint. The average reading age in the UK is that of an educated nine-year-old and the legacy of illiteracy and the ability to write is more widespread than previously believed. The opportunity to receive complaints by word of mouth will ensure that those members of the public who are unable to communicate effectively in writing will be considered. It would also be useful that consideration is given to advocacy support/ individuals are assisted in formulating their concerns.

23. However, there will need to be robust mechanisms to ensure that what the receiver of the complaint (PSOW staff) has recorded and what the complainant wants to say are the same. There will need to be clear guidance on the verification of the information and it may be necessary for PSOW staff to meet the complainant and agree the details of the complaint.

24. The NHS in Wales is working under Putting Things Right[iii] Regulations and is required to provide a response to oral complaints within 48 hours. It is unclear whether those principles will be applied to oral concerns taken by PSOW. If so this will place an immense amount of pressure in the system to accommodate a response.

25. Furthermore, we would need to consider the amount of information PSOW would be willing to accept as an oral concern before they would instigate an investigation. This could potentially increase the number of vexatious complaints received because of the ease of access and this would need to be monitored closely.

Q6. What other type/form of submission should be acceptable (e.g. email, website form, text messages)

26. To continue from the response to question 5, submissions should be acceptable in all formats to ensure it is as inclusive as possible for the population. This would include: text, email, web submission, letter, and orally either in person or over the telephone. There will need to be firm checks and balances in place across all of these formats so that the PSOW can be assured they have captured exactly what the complainant is requiring and to prevent misinterpretation. This approach is also congruent with the NHS Wales Putting Things Right procedures.

27. However, it is not just about the types of access that are acceptable as all NHS bodies in Wales use a variety of access routes highlighted above. The question should be around the type and level of information that would be required prior to starting an investigation. This should be clarified as there is a risk that work could be commenced on very little information or evidence.

Q7. Do you have a view on the financial costs and benefits of this provision?

28. Again it is difficult to quantify without further information. This will incur additional costs to implement initially, for example setting up relevant systems and processes to enable this to happen, additional staffing costs as the complaints will be taken orally and ensuring the complaints have been recorded correctly will take additional time. As this will also enable more people to raise complaints more easily to the PSOW it will almost certainly result in more complaints being raised, which will increase costs to both the PSOW office and the body being investigated. However, as highlighted, the benefits are that all members of the public with difficulties in writing or communicating will have the same opportunity as others to raise concerns.

Complaints handling across public services

Q8. At present there is no consistency in the way public bodies deal with complaints. Adoption of the model complaints policy issued by the Welsh Government is voluntary. What are your views on the Ombudsman preparing a model complaints policy which public bodies would be obliged to adopt? Please explain your answer.

29. The Welsh NHS Confederation does not believe that there should be a model complaints policy which all public bodies should work to because there are a number of strategies and policies with which different public bodies have to comply. The Ombudsman has a clear remit in supporting public sector complaints handling. How this would be executed requires further examination.

30. Any mandated model complaints policy would need to fully meet the legislative requirements placed on public sector organisations, for example National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. There has been a significant amount of work undertaken following the implementation of the Putting Things Right Regulations. Following this in 2014 the Minister for Health and Social Services asked for an independent review of complaint handling in Wales (the Keith Evans review). There were 109 recommendations and the National Quality and Safety Forum has already started to ensure an all-Wales approach has been established to achieve this. A number of work streams have begun and one is to review the Putting Things Right guidance which may influence our complaint policies so there is potential for duplication of work.

31. One of the main findings of the Keith Evans review was a lack of consistency, therefore the interpretation of an imposed complaints policy would become individual and subjective. Each health body adheres to the principles of the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

32. The role of PSOW is to ensure consistency in relation to process and administration and this responsibility is essential to ensure fairness and consistency. Given that the Welsh Government was the author of the Putting Things Right regulations and is currently leading on the current review, it would be appropriate for the body which owns the policy to define the policy. It is arguable that to empower the PSOW to develop policy could create a conflict in its subsequent role as an independent arbitrator and would suggest that this could detract from its current position.

33. It is also important to note an area of inconsistency and confusion with regard to redress. Putting Things Right clearly and succinctly defines redress. Given that the PSOW uses the same terminology in respect of its outcome - albeit defined significantly differently - this causes real problems in practice when dealing with patients and families. It is suggested that action should be taken to avoid any confusion between how PSOW interprets redress from that of other health bodies in Wales.[iv]

34. Further, it is felt that given the ongoing work streams of Putting Things Right, being led by the Welsh Government following the findings of the Keith Evans review, it is the wrong time to enforce a new policy. The role of the PSOW is vitally important as an independent arbitrator and as a consequence it would be more prudent for PSOW to focus on making recommendations when it identifies poor working practices and poor processes as part of its individual investigations and make suggestions how the complaints process could be improved. This would lead to improved consistency across Wales.

Q9. Do you have a view on the financial costs and benefits of this provision?

35. The model complaints policy across public sector bodies would have major benefits for the complainant and it would make multi-agency working easier. However, if the NHS in Wales were to adopt a complaints policy there would be a financial cost to change its policies in relation to Putting Things Right. There are clear disadvantages in relation to the potential conflicting view from the Keith Evans review, the principles outlined in Putting Things Right and the changes that would come from a complaint model being imposed by the PSOW.

Ombudsman’s jurisdiction

Q10. What are your general views on the Ombudsman’s current jurisdiction?

36. Overall the Welsh NHS Confederation believes that the current jurisdiction of the PSOW is appropriate and sufficiently extensive. Its role, as that of an independent arbitrator, cannot be understated and should not be compromised by the extension of its role. The focus on learning and service improvement by PSOW is commendable; however there is a lack of clear process in place for a cyclical approach to review and monitor the impact of its service improvement recommendations.

37. Within Wales there is clear access to free legal aid - both in appropriate cases through the existing legal system and also under Putting Things Right - which are clearly detailed under the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. There is a risk there would be duplicity if the current jurisdiction of the Ombudsman was extended. The access routes available to the public could become blurred and difficult to navigate because of multiple avenues available and as a consequence there would be potential for variation and waste in relation to the work of the courts.

Q 11. At present the Ombudsman can investigate private health care that has been commissioned by the NHS. The Ombudsman would like the jurisdiction to be extended to enable him/her to investigate when a patient has received private healthcare (self-funded not commissioned by the NHS) in conjunction with public healthcare. This would enable the complaints process to follow the citizen rather than the sector. What are your views on extending the Ombudsman’s jurisdiction in this way?

38. The Welsh NHS Confederation would agree with extending the PSOW’s jurisdiction in this way. It would be beneficial if the PSOW is able to reflect the population’s whole journey across public services, which may include private healthcare. Without this, the effectiveness of some public service investigations may be limited because the PSOW’s inability to investigate private care as part of an NHS patient’s journey/ pathway does mean that the PSOW cannot give the complainant a full response and this could be deemed unsatisfactory. Private care provision should be investigated with the same rigor and to the same standards as NHS services as patients could suffer the same detriment and the same degree of maladministration as within the NHS.

39. However, further clarity is required, for example would a private care provider be in accordance with the advice offered in an expert report? What would the sanctions be for failing to comply with a report and its recommendations and how would these be enforced?

Q 12. How do you think the investigation of private health care complaints should be funded? (Possibilities include a levy, charging on a case by case basis or no charge.)

40. The private healthcare industry would need to consider this with PSOW. The same principles and approach should be adopted for both private and NHS healthcare investigations. Any findings in regard to maladministration or service failings should have the same principles applied as NHS health care to ensure consistency.

Q 13. Do you have a view on the financial costs and benefits of this provision?

41. Depending on how many private healthcare investigations PSOW would undertake it would require additional PSOW staff and this will have a cost implication. This is likely to cost the service more but would benefit both the complainant and the service in terms of lessons to learn. A clear funding formula will be required so this does not impact on the public finances and there will need to be a comprehensive plan agreed with private healthcare providers.

Links with the courts

Q 14. What are your views on the removal of the statutory bar to allow the Ombudsman to consider a case which has or had the possibility of recourse to a court, tribunal or other mechanism for review (i.e. this would give complainants the opportunity to decide which route is most appropriate for them)?

42. This recommendation causes the Welsh NHS Confederation some concern due to the nature and details of the legal tests to be applied. This recommendation could create a dual tier of redress which, unless the existing identical legal tests were applied, could create inequity of approach between the systems. This was a point which was considered during the development of the Putting Things Right redress process. It is important that equity and consistency is maintained.

43. In addition, there is a risk that the PSOW will become an arbitrator of the legal tests and be in direct conflict with the courts, and more importantly in an area where there is a lack of specialised legal skills and knowledge. As a minimum, there would need to be clear guidance on when PSOW could intervene and also in terms of which cases. There would seem to be potential impact on a range of legislation which would all need careful consideration.

44. The current system using the Putting Things Right redress provides access for patients and families to free legal advice while maintaining the defined tests which ensures equality. The process has inbuilt ‘appeal’ mechanisms in that patients and families receive quality free legal advice from clinical negligence specialist solicitors in relation to the accepted common legal test applied in such cases. This covers whether the subject matter of the concern is actually legal qualifying liability in tort, and the appropriateness of the settlement of the valuation of damages.

45. This is an existing process which is embedded into NHS bodies’ culture and there is evidence in many cases that this works effectively for the benefit of both the patient and the health body. While there is a currently a cap on this of £25,000, this may be ultimately increased dependent upon the outcome of the review being undertaken in England. It is important that such a cap does apply between the legal complexities associated with higher value claims which require input from specialist lawyers.

Q 15. What are your views on the Ombudsman being able to refer cases to the Courts for a determination on a point of law?

46. The court and legal costs for such a referral will need to be determined. Where the point directly relates to the current arbitration role of the PSOW, this would be understandable, however, in all other cases, this may not be appropriate and such actions should be taken by parties with a direct interest in the subject matter of the issues.

47. Also it would need to be identified as to who funds any legal requests. There should also be consideration of the role of legal advice to clarify a point of law rather than proceeding directly to the courts.

Q 16. Do you have a view on the financial costs and benefits of this provision?

48. As highlighted previously this could be significant as it envisages the creation of a dual system with the potential for inbuilt inequity. It would be extremely expensive for the PSOW to equip itself with the necessary skills and qualified staff to undertake such a role without creating inequity as indicated above.

49. Given the current systems and processes, it is suggested that emphasis should be placed on the development of these current systems rather than the development of a system that duplicates what has already been established. If there are any financial costs, these should be borne by the PSOW not the NHS/public sector.

Other issues

Q 17. Do you have any specific examples where the Ombudsman having the additional powers proposed could have been useful in securing a successful conclusion to an issue?

50. We have no specific examples to provide but there have been some examples where the PSOW determinations and reports have adversely affected the course of litigation in previous cases.

Q 18. Schedule 3 of the current 2005 Act, provides a list of authorities that are within the Ombudsman’s jurisdiction to investigate complaints. Please provide details of any other bodies/organisations that should be included in this list?

51. As highlighted previously, it would be useful for private healthcare providers to be included within the PSOW’s jurisdiction to investigate complaints. The PSOW last year investigated nearly 2,000 complaints, therefore a concern would be that with the inclusion of additional authorities how will PSOW predict the amount of cases they would be investigating? With the suggestion of oral complaints this could result in a significant increase in work volume that has not been considered or mapped at this present time.

Q 19. If extended powers were given to the Ombudsman in a new Bill/Act, at what point should the impact of this legislation be evaluated?

52. If the extended powers were given, the impact should be evaluated on an annual basis and reported through the annual reporting process.

Q 20. What unintended consequences could arise as a result of these provisions becoming legislation and what steps could be taken to deal with these consequences?

53. There are some unintended consequences that could arise as a result of these provisions becoming legislation. For example:

a) There would be dual processes in place and there could be a misinterpretation of legal tests which could prejudice the NHS in Wales. This dual process would then lead to inequality across Wales as indicated in the detail above;

b) There is a potential that a small number of the population will use “own initiative” investigations as a form of a ‘public inquiry’;

c) There is the potential for some of the population to have repeated enquiries at a cost to public purse if the statutory bar is lifted;

d) It could lead to confusion between the PSOW’s powers and other regulators. Clarity on this would need to be established prior to it becoming legislation; and

e) Increased demand upon the Health Boards to review the increased number of concerns without any additional resource. The Keith Evans review was clear in its recommendations that concerns teams within the NHS need to have the necessary resources in terms of appropriate staffing levels. While it is proposed that the PSOW office would have additional resource of £270,000 per annum, these proposed changes will have an effect upon NHS concerns teams and this should also be considered and resourced appropriately.

Q 21. What factors should be measured to determine the cost-benefit analysis of this legislation being brought forward?

54. The clear outcomes for the public need to be measured in line with the costs. Additional outcomes would be tangible changes made to services / parts of services as a result of this legislation. It is important that the focus is not only on process measures.

55. As part of the cost-benefit analysis the level of fine by the PSOW must be considered, the number of cases taken on by the PSOW, which may increase due to additional route of submission, the number of second responses to the PSOW and complainants satisfaction with the outcome.

Q 22. Do you have any comments on the following issues:

- jurisdiction – changes to the devolution settlement have led to new areas coming into jurisdiction over time, should consideration be given to other bodies being included in the Ombudsman’s jurisdiction;

56. As highlighted previously private providers and companies as well as individuals, should be included.

- Recommendations and findings - should the recommendations of the Ombudsman to public bodies be binding. This would mean that bodies cannot decide to reject the findings;

57. Overall the Welsh NHS Confederation believes that the recommendations of the PSOW should not be binding. There should be an opportunity for a dialogue between the PSOW and Health Board to agree the findings. There have been a small number of occasions when the recommendations arising from an investigation have either been un-implementable or the conclusions from which they have been drawn have been incorrect. Thus far the particular Health Board has been able to negotiate accordingly with the Ombudsman in respect of these.

- Protecting the title – there has been a proliferation of schemes calling themselves ombudsmen, often without satisfying the key criteria of the concept such as independence from those in jurisdiction and being free to the complainant. Should anyone intending to use the title ombudsman gain approval from the Ombudsman;

58. Approval should be gained but we do not believe it can come from the PSOW as there are other regulatory Ombudsman services, for example the Financial Service Ombudsman.

- Code of conduct complaints – the Ombudsman would prefer to focus on the element of his work that deals with service users and service delivery, rather than local authority and town and community councils’ resolutions. Whilst a local resolution procedures exists and has been adopted by 22 local authorities, variance exists in practice.

59. We agree that the PSOW should focus on the elements of his work that deal with service users and service delivery but the PSOW must also engage with the Local Authority and town and community councils.

Q 23. Do you have any views on any aspects of future planned or proposed public sector reforms that would impact on the role of the Ombudsman?

60. The Act should be as future proofed as much as possible to fully take proposed public sector reforms into consideration.

61. In relation to Local Government reforms, the Welsh NHS Confederation, on behalf of its members, has engaged significantly with the proposed changes. We welcomed the publication of the Williams Commission report and we responded to its recommendations, highlighting that we recognised that they have the potential to support better integration and reduce overall demands on health, and drive improvements across the board. However, to date, Local Government re-organisation has dominated the debate surrounding the White Paper and the Commission’s findings. Although the debate is a key part of refocusing public services in Wales we are concerned that this remains the focus. The potential reduction in the numbers of Local Authorities should aid multi-agency working. Working with fewer Local Authorities will streamline the integration process for Health Boards, and there will be fewer structural barriers to collaborative working across the board.

Q 24. Do you have any other issues or concerns about the current Act and are there any other areas that need reform or updating?

62. There should be a comprehensive impact assessment carried out on the proposed changes. It is reported that the workload of the PSOW increased by 11% last year.[v] The proposed changes will potentially increase its workload exponentially and it would be prudent to ask how the PSOW office intends to manage this unpredicted demand.

63. One of the main challenges for the NHS in Wales is the lack of learning from events. Following conclusion of their investigation PSOW should focus on learning. There should be a system of accountability and a review following the acceptance of PSOW recommendations. PSOW could hold a library of learning that could be used by other health bodies experiencing the same challenges. If an evaluation of a health body is undertaken following implementation of the recommendations and there is no evidence of learning or change then an escalation route could be introduced to HIW for further monitoring and consideration. Furthermore it may be more appropriate for the PSOW office to sit within a framework and a wider system within Wales and work with the existing regulators.