Agenda Document Pack - Clinical and Care Governance Committee - 26/02/2026
Moray Council · 26 February 2026
Back to Clinical and Care Governance Committee — 26 February 2026 and its agenda
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Clinical and Care Governance Committee Thursday, 26 February 2026 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Clinical and Care Governance Committee, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 26 February 2026 at 13:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 28 August 2025 5 - 8 4. Action Log - 28 August 2025 9 - 10 Effective Communication and Information 5. Complaints Report for Quarters 1, 2 and 3, 2025/2026 11 - 26 6. Drug Related Deaths in Moray 27 - 30 Safe and Effective Practice 7. Health and Social Care Moray Clinical and Care Governance Group Escalation Report 31 - 52 8. Items for Escalation to MIJB Page 1
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Item(s) which the Committee may wish to consider with the Press and Public excluded 9. CONFIDENTIAL Primary Care Update • 1. Information relating to a particular employee, former employee or applicant to become an employee of, or a particular office- holder, former office-holder or applicant to become an office- holder under, the authority. Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Derick Murray (Chair) Councillor Peter Bloomfield (Voting Member) Councillor Scott Lawrence (Voting Member) Mr Alex Stephen (Voting Member) Professor Duff Bruce (Non-Voting Member) Mrs Sheila Brumby (Non-Voting Member) Ms Helen Chisholm (Non-Voting Member) Mr Sean Coady (Non-Voting Member) Ms Miriam Connor (Non-Voting Member) Dr Robert Lockhart (Non-Voting Member) Mr Jim Lyon (Non-Voting Member) Ms Aimee McIntosh (Non-Voting Member) Ms Deborah O'Shea (Non-Voting Member) Ms Judith Proctor (Non-Voting Member) Ms Elizabeth Robinson (Non-Voting Member) Mrs Christine Stevens (Non-Voting Member) Clerk Name: Caroline O'Connor Clerk Telephone: 07779 999296 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE CLINICAL AND CARE GOVERNANCE COMMITTEE Thursday, 28 August 2025 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Councillor Peter Bloomfield, Ms Helen Chisholm, Councillor Scott Lawrence, Dr Robert Lockhart, Mr Jim Lyon, Mr Derick Murray, Ms Deborah O'Shea, Ms Elizabeth Robinson, Mr Sandy Riddell APOLOGIES Mr Ivan Augustus, Professor Duff Bruce, Mrs Sheila Brumby, Mr Sean Coady, Ms Judith Proctor, Mr Alex Stephen IN ATTENDANCE Corporate Manager; Corporate Business Support Manager and Caroline O'Connor, Committee Services Officer. 1. Chair The meeting was chaired by Mr Derick Murray. 2. Declaration of Member's Interests There were no declarations of Member's interests in respect of any item on the agenda. 3. Minute of meeting of 27 February 2025 The minute of the meeting of 27 February was submitted and approved. 4. Action Log - 27 February 2025 The Action Log of the meeting of 27 February 2025 was discussed and updated accordingly. Item 3. Page 5
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5. Health and Social Care Moray Clinical and Care Governance Group Escalation Report The meeting had before it a report by the Chief Nurse, Moray informing the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in February 2025. During discussion Councillor Lawrence expressed concern regarding the pressures on GPs in Moray in terms of direct clinical encounters being much higher than neighbouring authorities and the pressures were also impacted by gaps in mental health provision as outlined in Appendix 2. In response, the Chair confirmed he shared the concerns relating to the pressures on GPs and had shared the figures with the Chair of the NHS, the Council Leader, the Public Health Chair and the Interim Director of Public Health in NHS Grampian for consideration. Following consideration the Committee unanimously agreed to note the contents of the report. 6. Health and Social Care Moray Clinical Risk Management Terms of Reference The meeting had before it a report by the Chief Nurse, Moray informing the Committee of the updated Terms of Reference for the Health and Social Care Moray Clinical Risk Management Group and outlining it's purpose, remit and reporting arrangements. Following consideration the Committee unanimously agreed to:- (i) note the updated Terms of Reference for the Clinical Risk Management Group (Version 3.0, August 2025) which reflect current governance structures and professional leadership within Health and Social Care Moray; and (ii) endorse the continued role of the Clinical Risk Management Group in providing assurance on clinical risk and governance matters, and its reporting relationship to the Clinical and Care Governance Group and, where appropriate, to NHS Grampian. 7. Draft Health and Social Care Moray Annual Complaints Report 2024-25 The meeting had before it a report by the Chief Nurse, Moray providing the Committee with the Draft Health and Social Care Moray Annual Complaints Report for 2024/25. Following consideration the Committee unanimously agreed to:- (i) note the contents of the annual report; and (ii) request the annual report is submitted to Moray Integration Joint Board in September for approval prior to publication. 8. Items for Escalation to MIJB During discussion and following on from the concerns raised on the Health and Social Care Moray Clinical and Care Governance Group Escalation Report specifically relating to the pressures on GPs in Moray and the related gaps in mental health services, Page 6
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Councillor Lawrence suggested it may be appropriate to escalate the report to the next Moray Integration Joint Board meeting. Dr Lockhart advised it was intended to provide a more detailed report for the next meeting of this Committee however noted the next meeting was scheduled for February 2026 and there may be an increase in pressures during winter. Following consideration the Committee unanimously agreed the Health and Social Care Moray Clinical and Care Governance Group Escalation Report be escalated to the next meeting of Moray Integration Joint Board on 25 September 2025. Page 7
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MEETING OF MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE THURSDAY 28 AUGUST 2025 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FEBRUARY 2026 1. HSCM Clinical and Care Governance Group Escalation Report 27/02/25 Uptake figures for drop-in sessions at Aberlour Health Hub to be circulated to Committee. Work to be undertaken to refresh the Terms of Reference (TOR) in April 2025 following conclusion of national work relating to the practice governance elements and reported back to Committee in due course. TBC February 2026 Deputy Chief Officer Corporate Manager Included in HSCM CCG Group Escalation report August 2025. Action Closed. Update included in CCG Group Escalation report on today’s agenda. 2. HSCM Clinical and Care Governance Group Escalation Report / Items for Escalation to MIJB 28/08/25 To be escalated to next meeting of MIJB on 25 September 2025 25 Sep 2026 Corporate Manager Update on General Practice Sustainability escalation included in HSCM CCG Group Escalation report on today’s agenda. Item 4. Page 9
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: COMPLAINTS REPORT FOR QUARTERS 1, 2 AND 3, 2025/2026 BY: CHIEF NURSE - MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of complaints and feedback reported and closed during Quarters 1, 2 and 3 (1 April 2025 – 31 December 2025). 2. RECOMMENDATION 2.1 It is recommended that the Committee considers and notes the totals, lessons learned, response times and action taken for complaints completed within the first three quarters of 2025/26. 3. BACKGROUND 3.1 Within Health and Social Care Moray (HSCM), complaints received by NHS Grampian (NHSG) and Moray Council are recorded on 2 separate systems, in accordance with the appropriate policy and procedure of these organisations. 3.2 At the meeting on 27 February 2020 (para 7 of the minute refers), it was agreed that a combined report from NHSG and Council complaints systems be submitted to future meetings of the Committee. At the Committee meeting on 27 August 2020 (para 14 of the minute refers) it was requested that the procedures be explained to demonstrate the similarities and differences, if any. 3.3 NHS and Local Authority (LA) Complaint Handling Procedure/Policy requires all staff to deal with feedback and complaints in a person/client-centred way. The procedure has been developed working closely with the Scottish Public Services Ombudsman (SPSO). There is a standard approach to handling complaints across the NHS and Local Authority, which complies with the SPSO's guidance on a model complaint handling procedure and meets all of the requirements of the Patient Rights (Scotland) Act 2011, and accords with the Healthcare Principles introduced by the Act. Item 5. Page 11
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3.4 The complaints process followed by both NHSG and Moray Council have the same target response timescales. Early resolution, or front line, complaints will be responded to within 5 working days and complaints handled at the investigation stage have a response time of 20 working days. Where it is not possible to complete the investigation within 20 working days an interim response should be provided with an indication of when the final response should be provided. 3.5 The decision as to whether the complaint is upheld or not will be made by the manager or Head of Service. If the person raising the complaint is not satisfied with the outcome, then they may contact the SPSO for an independent review and assessment, however prior to this, every effort is made to engage with the complainant to resolve the matter to their satisfaction. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Committee is presented with quarterly complaints performance information using the mandatory Key Performance Indicators (KPIs), published by SPSO in March 2022. These are: Indicator One The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Indicator Two The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full Indicator Three The average time in working days for a full response to complaints at each stage The average time in working days to respond at stage 1, stage 2 and after escalation Indicator Four The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation 4.2 The qualitative indicator on learning from complaints has been removed. However, Part 4 of the SPSO Model Complaints Handling Procedure on Governance stresses the importance of learning from complaints, and the requirements to record and publicise learning. Therefore, learning from complaints will continue to be included in quarterly complaints performance reports and annual complaints reports. Page 12
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4.3 HSCM Complaints performance data for Quarter 1, 2 and 3 is attached at Appendix 1. 4.4 Information about complaints referred to the Ombudsman are also included along with any complaints relating to the actions and processes of Moray Integration Joint Board (MIJB). 4.5 Figures reported do not include complaints raised regarding the vaccination appointments or processes as these are being dealt with through a dedicated team covering the Grampian area. Any complaints or comments regarding the Moray Vaccination Centre in Elgin are included in reported figures. 4.6 Out of Hours Primary Care Service (known as GMED) is hosted by the MIJB for the whole of Grampian. GMED service cares for patients who have urgent care needs and cannot wait until their GP Practice is open. GMED operates 18:00 until 08:00 each weekday, all weekends and each public holiday including the festive period. Therefore, figures presented for GMED are for a Grampian wide service that on average sees around 90,000 contacts annually (1/6 of the Grampian population). 4.7 Following ministerial approval, Children and Families and Justice Social Work Services were formally delegated by the Local Authority to MIJB on 16 March 2023. All complaints and enquiries received regarding these services and recorded on Lagan are captured in Appendix 1 and the figures below. Complaints 4.8 The table below sets out total number of complaints received and closed (HSCM), per quarter, for the first three quarters of 2025/26. Received Q1 25/26 Closed Q1 25/26 Received Q2 25/26 Closed Q2 25/26 Received Q3 25/26 Closed Q3 25/26 NHS 14 13 18 22 22 23 Council 25 28 21 18 27 17 39 41 39 40 49 40 4.9 The chart below sets out HSCM complaints received and closed by Quarter. Children and Families and Justice Social Work services figures are included from Q1 2023/24 onwards. 31 37 42 37 28 35 36 38 39 39 49 34 34 37 38 22 25 37 36 41 40 40 0 10 20 30 40 50 60 Q1 23/24 Q2 23/24 Q3 23/24 Q4 23/24 Q1 24/25 Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26 Q3 25/26 Received Closed Linear (Received) Page 13
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MP/MSP Enquiries 4.10 There were 31 MP/MSP enquiries received (in this reporting period) regarding council services, under HSCM (including Children and Families and Justice), and recorded on the Council system, Lagan. These were allocated as follows: Service Number of Enquiries HSCM – Access Team 5 HSCM – Care at Home 6 HSCM – Community Care Finance 4 HSCM – Hospital Discharge Team 1 HSCM – Learning Disability 1 HSCM – Mental Health 1 HSCM – Moray West 4 HSCM – Occupational Therapy 4 Children and Families and Justice Social Work – Access Team 1 Childres and Families Area Teams 3 Children and Families and Justice Social Work – Throughcare 1 4.11 7 are still under investigation, at the time of reporting. 4.12 As of 1 April 2024, all general MP/MSP enquiries received by NHS Grampian Chief Executive Office, regarding health services, and specific to Moray, are forwarded direct to Service Managers in Moray to handle, in their entirety. To support this change HSCM have streamlined their operational procedures for handling enquiries which has improved efficiency, management oversight, consistency in responses, time management and data collection. 4.13 There was 9 MP/MSP enquiry received regarding health services, under HSCM, during this reporting period. These were in relation to a variety of matters as set out below: Service Number of Enquiries Community Alcohol Partnerships 1 MIDAS 1 Vaccinations 1 Health Visting 1 Vaccination Centre 1 Ear Wax Removal Services 1 Community Hospitals 1 Locality Event 1 GP Services 1 4.14 Any patient specific MP/MSP enquiries continue to be logged on Datix, and processed by NHS Grampian, either as a complaint, concern or comment, and captured in figures presented today. Page 14
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4.15 A number of Councillor enquiries have been received, however, as these are not formally recorded on either Lagan or Datix it is not possible to accurately report on enquiries received and responded to. Concerns and Comments 4.16 There were 6 concerns received, investigated and responded to in this reporting period and recorded on Datix, these were for Adult Mental Health Services and Moray Vaccination Centre. Compliments 4.17 There were 8 compliments received in this reporting period and recorded on Datix, these were for teams in GMED, Physiotherapy, Community Nursing and Elgin Vaccination Centre. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. Effective handling of complaints is used to ensure the efficient and sustainable delivery of services to meet priorities. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the HSCM Senior Leadership Team and to the Clinical and Care Governance Committee. There are platforms within Health and Social Care to discuss and share good practice, learning and challenges. MIJB, Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. Page 15
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(e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. (f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact Not required as there are no changes to policy. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff who are in agreement with the content of this report where it relates to their area of responsibility: • Corporate Manager, HSCM • Caroline O’Connor, Committee Services Officer, Moray Council • HSCM Clinical and Care Governance Group 6. CONCLUSION 6.1 This report provides a summary of HSCM complaints and enquiries received and closed during the first three quarters of 2025/26 (1 April – 31 December 2025). The governance and monitoring of complaints forms part of core business for teams and services and the provision of a good quality, effective and safe service is a key priority for all. Author of Report: Isla Whyte, Corporate Business Support Manager Background Papers: with author Ref: Page 16
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APPENDIX 1 Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Learning from complaints Teams and services actively review all forms of feedback to see where improvements can be made and share any learning. The tables 1, 2, 3, 4, 5 and 6 below set out the outcomes of closed complaints, what service received the complaint and any actions taken /learning. Complaints Information Extracted from Datix – 58 complaints were closed during Quarters 1, 2 and 3, 2025/26. Table 1 Actions Taken/Outcome of complaints closed during Quarters 1,2 and 3, 2025/26: Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Consent not received: Consent form not received from patient Irresolvable - funding: Complaint is irresolvable due to funding difficulties Complaint withdrawn: Complaint not taken forward Irresolvable - other: Other reasons not listed Total Communication - Improvements in communication staff-staff or staff- patient 4 17 1 1 0 0 0 23 Education/training of staff 1 4 0 0 0 0 0 5 No action required 0 1 18 1 2 4 1 27 Access - Improvements made to service access 1 1 0 0 0 0 0 2 Conduct issues addressed 1 1 0 0 0 0 0 2 Share lessons with staff/patient/public 1 5 0 0 0 0 0 6 Action plan(s) created and instigated 0 1 0 0 0 0 0 1 Waiting - Review of waiting times 0 1 0 0 0 0 0 1 Risk issues identified and passed on 0 0 0 0 2 0 0 2 Total 8 31 19 2 4 4 1 *69 *this figure does not represent the number of complaints closed as complaints may have more than one action Page 17
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Table 2 Complaints Information Extracted from Lagan: 63 complaints were closed during Quarters 1, 2 and 3, 2025/26 Directorate Department Service Upheld Partially Upheld Not Upheld Resolution Grand Total Health and Social Care Moray Children and Families and Criminal Justice Access Team 3 5 10 2 20 Children and Families Area Teams 0 3 11 2 16 Fostering and Adoption and Supported Lodgings 0 0 1 2 3 Throughcare 1 0 0 0 1 Health and Social Care Moray Access Team 3 6 7 0 16 Care at Home 1 0 1 0 2 Community Care Finance 0 1 0 0 1 Learning Disability 1 1 0 0 2 Mental Health 0 1 1 0 2 Page 18
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Table 3 Complaints Information Extracted from Datix: 58 complaints were closed during Quarters 1, 2 and 3, 2025/26 Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Consent not received: Consent form not received from patient Irresolvable - funding: Complaint is irresolvable due to funding difficulties Complaint withdrawn: Complaint not taken forward Irresolvable - other: Other reasons not listed Total Allied Health Professionals 1 2 1 0 0 0 0 4 Community Hospital Nursing 0 1 2 1 0 0 0 4 Community Nursing 0 2 1 0 0 0 0 3 General Practice 0 1 0 0 0 1 0 2 GMED 3 8 7 0 0 0 0 18 Grampian Vaccination and Immunisation Programme 1 0 2 0 0 0 0 3 Mental Health - Adult Mental Health 1 8 5 1 3 3 1 22 Mental Health - Old Age Psychiatry 0 0 1 0 0 0 0 1 Mental Health - Specialisms 0 0 0 0 1 0 0 1 Total 6 22 19 2 4 4 1 58 Page 19
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Table 4 Complaints Information Extracted from Datix – Action Taken by Service (complaints closed during Quarters 1,2 and 3, 2025/26) Access - Improvements made to service access Communication - Improvements in communication staff-staff or staff- patient Action plan(s) created and instigated Conduct issues addressed Education/ training of staff Share lessons with staff/ patient/public Waiting - Review of waiting times No action required Risk issues identified and passed on Total Allied Health Professionals 1 3 0 1 1 0 0 1 0 7 Community Hospital Nursing 0 2 0 1 0 0 0 2 0 5 Community Nursing 0 1 1 0 0 0 0 1 0 3 General Practice 0 1 0 0 0 0 0 1 0 2 GMED 0 10 0 0 4 1 0 7 0 22 Grampian Vaccination and Immunisation Programme 0 1 0 0 0 1 0 2 0 4 Mental Health - Adult Mental Health 1 5 0 0 0 4 1 12 1 24 Mental Health - Old Age Psychiatry 0 0 0 0 0 0 0 1 0 1 Mental Health - Specialisms 0 0 0 0 0 0 0 0 1 1 Total 2 23 1 2 5 6 1 27 2 *69 *this figure does not represent number of complaints closed as complaints may have more than one action. Page 20
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Active review of complaints through reporting and investigation is a useful tool to identify learning and improve services. Below are some of the actions and learning from complaints closed in Quarters 1, 2 and 3, 2025/26. Information provided is kept brief to ensure no patient identifiable information is shared. Table 5 Actions and Lessons Learned (Datix) Communication Improvement in Communication Skills – individual learning undertaken Reminder to team about ensuring communication is clear Team discussed ways to communicate with patients and reminded of importance of ensuring patient has clear understanding of next steps Individual learning regarding communication and ward procedures Communication – team training to take place Action Plan Team currently reviewing and strengthening Safety Calling Protocol All learning points will be added to trainee doctor e-portfolio, which is a mandatory requirement during training Share Lessons New process implemented regarding rejected referrals. Shared Learning Summary completed and shared appropriately Shared Learning Template completed for vaccination team Communication Improvements (staff to staff or staff to patient) continues to be the most common theme arising from complaints. Table 6 Learning Outcomes (Lagan) Revision Process / Procedure Recommendation made to department to devise a process for management of meeting minutes Reinforcement of Process / Procedure Team training around communication Discussion with team around importance of following process Reflective practice undertaken regarding language used in professional context Brief circulated to staff regarding the importance adhering to communication requests Attention to detail in documentation – reminder to staff Other Investigating telephony system to ensure unanswered calls can be diverted Communication and following procedure continue to be the main themes arising from complaints. Page 21
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Indicator 1 – The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Table 7 – Total number of complaints received in Quarters 1, 2 and 3, 2025/26 System recorded Early Resolution / Frontline (Stage 1) Investigation (Stage 2) Not Marked Total NHS – Datix 24 30 0 54 Moray Council - Lagan 27 28 18 73 Total 51 58 18 127 Table 8 – Allocation of complaints received in Quarters 1, 2 and 3, 2024/25 NHS Service - Datix Allied Health Professionals 3 GMED 15 Community Nursing 3 Community Hospital Nursing 3 Mental Health - Specialisms 1 Mental Health – Old Age Psychiatry 1 Mental Health – Learning Disabilities 1 Mental Health - Adult Mental Health 20 General Practice 2 Vaccination Transformation Programme 5 Total 54 Table 9 – Allocation of complaints received in Quarters 1, 2 and 3, 2025/26 Page 22
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) MC Service - Lagan Children and Families and Criminal Justice Access Team 17 Cala 1 Children and Families Area Teams 18 Throughcare 1 Youth Justice 1 Health and Social Care Moray Access Team 18 Access Team Adult Care 2 Care at Home 4 Community Care Finance 2 Learning Disability 3 Mental Health 3 Moray East 1 Moray West 2 Total 73 Indicator 2 - The number and percentage of complaints at each stage which were closed in full within the set timescales of 5 and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full. There were 58 Complaints closed on the NHS system Datix during Quarters 1, 2 and 3, 2025/26 – breakdown as follows: Early Resolution/Stage 1 4 Investigation/Stage 2 33 Escalated Stage 2 19 SPSO 2 There were 63 Complaints closed on the MC system Lagan during Quarters 1, 2 and 3, 2025/26 – breakdown as follows: Early Resolution/Stage 1 31 Page 23
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Investigation/Stage 2 29 Escalated Stage 2 3 Table 10 – number and percentage of complaints at each stage closed within timescales (based on complaints closed during Quarters 1, 2 and 3, 2025/26) Frontline/Early Resolution within timescale Investigation within timescale Escalated Investigation NHS - Datix 1 out of 4 (25%) 12 out of 33 (36%) 5 out of 19 (26%) Moray Council - Lagan 9 out of 31 (30%) 1 Extension (completed in timescale) 11 out of 29 (40%) 2 Extensions (1 completed in timescale) 1 out of 3 (33%) 1 Extension (not within timescale) Whilst HSCM aim to respond to complaints within timescales this is not always achievable. Complaints received are often multi-faceted and include more than one service and other sectors, which can impact on response times due to the level of investigation and coordination required. Overdue complaints are reported to the Senior Management Team (SMT) on a fortnightly basis for appropriate oversight. This ensures that more complex cases are highlighted and helps SMT identify patterns and address recuring issues. Indicator 3 - The average time in working days for a full response to complaints at each stage Table 11 – average time in working days to respond at stage 1, stage 2 and after escalation (based on complaints closed during Quarters 1, 2 and 3, 2025/26) Frontline Investigative Escalated Investigative NHS - Datix 7 days 71 days 41 days Moray Council - Lagan 67 days 34 days 84 days Page 24
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Indicator 4 - The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation. Graph 2 below shows the number of complaints fully upheld, partially upheld and not upheld as recorded in Datix during Quarters 1, 2 and 3, 2025/26. 58 complaints were closed: 2 were closed as no consent was received, 5 were irresolvable and 4 were withdrawn. From the remaining 47: 13% were upheld, 47% were partially upheld and 40% were not upheld. 0 2 4 6 8 10 12 Early Resolution Investigation Escalated Investigation SPSO Complaints Outcome (Datix) Fully Upheld Partially Upheld Not Upheld Page 25
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Complaints Data Quarter 1, 2 and 3 (01/04/25 – 31/12/2025) Complaints Information Extracted from Lagan: Graph 3 below shows the number of complaints upheld, partially upheld and not upheld as recorded in Lagan. 63 complaints were closed during Quarters 1,2 and 3, 2025/26: 14% were fully upheld, 27% partially upheld, 49% were not upheld and 10% were resolved. 0 2 4 6 8 10 12 14 16 18 20 Frontline Investigation Escalated Investigative Complaints Outcome (lagan) Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not Upheld: Complaint is not accepted Resolution Page 26
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: DRUG RELATED DEATHS IN MORAY BY: INTERIM SERVICE MANAGER, MENTAL HEALTH AND DRUG AND ALCOHOL SERVICES 1. REASON FOR REPORT 1.1 To update the Committee about drug-related deaths in Moray. 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note: i) the drug related death figures for Moray; ii) ongoing work of the service in relation to the Multi Agency Risk System (MARS) process; iii) the National Benchmarking report on the implementation of the Medication Assisted Treatment (MAT) Standards: Scotland 2023/24; iv) the work being done on the Moray residential rehabilitation pathway; and v) the development of a strategic group and lived experience panel to align the Moray strategy and the National Mission. 3. BACKGROUND 3.1 The National Records of Scotland (NRS) publish, annually, the Drug-related Deaths in Scotland figures. The report on the 2024 figures is now available, published in September 2025 and can be accessed online: Decrease in drug misuse deaths - National Records of Scotland (NRS). Item 6. Page 27
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 National Records of Scotland confirmed that Moray had 10 confirmed drug related deaths in 2024, the same number as in 2023. 60% of these were known to secondary care services, either at the time of death or previously. 4.2 MARS remains an active process within the service for those at highest risk for which all communication routes have been exhausted and the risk persists. Currently, no individuals are within the MARS process, and this has been the case for some time. This is partly due to the level of support already provided to individuals, however many continue to experience significant risk. Other mechanisms are in place to reduce this risk, including assertive outreach, the Duty Worker Team (MIDAS and Arrows), and the Arrows Fieldwork Team who all undertake ongoing ad hoc/assertive outreach. A number of individuals supported by the service are also open to Adult Support and Protection and Multi-Agency Risk Reduction Assessment and Coordination (MARRAC) processes. 4.3 Moray has achieved Red, Amber, Green, Blue (RAGB) green rating for MAT Standards 1–10, with the exception of MAT 2 which is rated blue (achieving blue after two years of consecutive green rating) for their 2025 submission. Preparation is underway for the 2026 submission (numerical, process and experiential evidence), with the team hopeful that at least half of the standards will achieve blue rating in April. Consideration is also being given to how this work will continue locally once the National Mission concludes later this year, with a focus on embedding a human-rights-based approach and upholding the Charter of Rights for people who use substances. 4.4 Moray Integrated Drug and Alcohol Service (MIDAS) Death Review meetings are chaired locally and all reports are held confidentially. Meetings are well attended by partner agencies and although demand-led they typically occur two/three times per month. Reviews are completed for every notified death in Moray where drugs and/or alcohol are identified as a primary or contributing factor. Work is underway to determine how learning and outcomes from these reviews can be shared safely. The overall process is currently being reviewed to ensure alignment with the Charter of Rights for people who use substances and Public Health Scotland’s draft guidance Preventing Substance-Related Harms by Case Review, Learning and Action Following a Death. 4.5 The MAT Working Group continues to meet regularly, on average two meetings per month, to support delivery of the MAT Standards in Moray. Future planning is underway, with several actions already implemented, including the expansion of MAT 1 to cover poly-substance use rather than focusing solely on opioid substitution therapy (OST). Page 28
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4.6 The Residential Rehabilitation Pathway is under review following the recruitment of a Rehab Support Worker at Arrows, reflecting increased demand for rehabilitation services. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” Moray Drug and Alcohol Partnership Delivery Plan 2021 - 2024 (reviewed and revised November 2022). (b) Policy and Legal Improved governance – review and reporting of all drug and alcohol related deaths. Delivery in line with Rights, Respect and Recovery 2018 – Scotland’s strategy to improve health by preventing and reducing alcohol and drug use, harm and related deaths, the aim of the National Mission on Drug Deaths Plan 2022-2026 to reduce drug deaths and improve lives and the Scottish Government Phase One Report: Good Practice Guide for Pathways Into, Through and Out of Residential Rehabilitation Scotland. (c) Financial implications There are no financial implications. The Adverse Event Review Process and Multi Agency Risk System approach are undertaken by existing staff and multi-agency partners. (d) Risk Implications and Mitigation As detailed above at Section 4. (e) Staffing Implications Additional staff have already been appointed to support delivery of MAT standards, as well as meet increased demand on services. However, there are ongoing difficulties in relation to medical staffing within the service which may impact on the ability to deliver care in a timely manner. (f) Property Current accommodation remains not fit for purpose and does not allow service to comply with all of the MAT standards. In addition, co-location with the Justice Service can be seen as a barrier to people accessing treatment. Work continues to secure alternative premises for the service, however, to date this has been unsuccessful. (g) Equalities/Socio Economic Impact None arising directly from this report as there is no change to policy. (h) Climate Change and Biodiversity Impacts None arising directly from this report. Page 29
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(i) Directions None arising from directly from this report. (j) Consultations Public Protection Lead, Moray Alcohol and Drug Partnership Manager, Alcohol and Drug Partnership Co-ordinator, Clinical Team Lead, Moray Integrated Drug and Alcohol Service and Caroline O’Connor, Committee Services Officer, Moray Council. Comments have been incorporated in this report. 6. CONCLUSION 6.1 Moray's strategy to reduce drug-related deaths is supported by regular reviews, the Multi Agency Risk System (MARS), and the Medication Assisted Treatment (MAT) standards. The combination of daily high-risk event monitoring and MAT multi-disciplinary meetings ensures timely responses to individuals at greatest risk. These collaborative efforts help manage risk and reduce harm for vulnerable individuals in service. Author of Report: Lynne Clark, Interim Service Manager Background Papers: Ref: Page 30
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: HEALTH AND SOCIAL CARE MORAY CLINICAL AND CARE GOVERNANCE GROUP ESCALATION REPORT BY: CHIEF NURSE – MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in August 2025. 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note the contents of the report. 3. BACKGROUND 3.1 Health and Social Care Moray (HSCM) Clinical Governance Group was established as described in a report to this Committee on 28 February 2019 (para 7 of the minute refers). 3.2 The assurance framework for clinical governance was further developed with the establishment of the Clinical Risk Management Group (CRM) as described in a report to this Committee on 30 May 2019 (para 7 of the minute refers). 3.3 As reported to this Committee on 29 October 2020 (para 5 of the minute refers) Social Care representatives attend the Clinical Governance Group, so the group was renamed HSCM Clinical and Care Governance (CCG) Group. 3.4 A refresh of the Terms of Reference for the HSCM CCG Group was undertaken in 2023 and reported to this Committee on 30 November 2023 (para 6 of the minute refers). 3.5 This report contains information reported to HSCM CCG Group from Clinical Service Groups / departments. This report also contains further information Item 7. Page 31
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relating to incidents / adverse events reported via Datix and areas of concern / risk and good practice shared during the reporting period. 3.6 The meeting schedule of the MIJB does not always align to quarterly reporting. It has been agreed that the Escalation Report should include the CCG Group meetings between committee scheduling to ensure committee is provided with the most up to date information; this may not always be quarterly. 3.7 The CCG Group have met 5 times during this reporting period. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Audit, Guidelines Reviews and Reports 4.1 Relevant Audits, Guidelines Reviews and Reports are presented and discussed at CCG Group. These include local and national information that is relevant to HSCM, for example, recommendations from Health Improvement Scotland (HIS) reports from other areas which require to be discussed, and assurance given that services in Moray are aware of these and have processes in place to meet / mitigate the report recommendations. Overview of items discussed during this reporting period are listed below: • CRM Minutes • External Reports • Service Reports • Adverse Events and Duty of Candour • HSCM Risk Register • Complaints / Feedback • Update from Practice Governance Group Areas of achievement / Good Practice – highlighted at the CCG Group Realistic Medicine and Making Every Opportunity Count (MEOC) 4.2 Realistic Medicine is about finding out what matters most to the people HSCM support and care for. See Appendix 1 for more information about these initiatives, and benefits highlighted from practitioners and patients. Social Prescribing 4.3 A basic framework for social prescribing exists in Moray, efforts are now focused on enhancing this to facilitate effective scale up. Project progressing as planned, with an anticipated rollout across all areas by April 2026, in some form, and a more detailed structure is being refined in the upcoming months. However, the Healthpoint Team who will be integral to progressing this piece of work are operating at 50% capacity due to vacancy control measures. The team are limited to undertake additional responsibilities while maintaining core Healthpoint services. Grampian Wellbeing Festival 4.4 The Grampian Wellbeing Festival 2025 in Moray engaged 43 organisations to deliver diverse community-based activities focused on mental health and wellbeing. The festival offered a month-long programme of inclusive, community- Page 32
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based activities aimed at promoting mental health and wellbeing. The festival is paused in Moray and Aberdeenshire this year, due to staff capacity, funding and resource. The Steering Group will be reviewing the festival and outcomes to inform future delivery. Initial thoughts are that a more targeted approach is needed to ensure HSCM reach the right people. HSCM continue to promote online wellbeing resources. Student Placements (GMED) 4.5 In 2025, the University of Aberdeen (UoA) awarded a Certificate of Excellence Commendation to the UoA GP teaching team and NHSG's Out of Hours (OOH) Primary Care team, GMED. This award recognised the development of a fourth year medical student placement programme in OOH primary care, traditionally an area of medicine that students have had little exposure to. These rolling placements not only develop clinical knowledge around the conditions that present during the OOH period and the treatment options to manage them, it allows observation of the interface between primary, secondary, and tertiary care. Vitally, it is hoped that early introduction to the service might also raise awareness for OOH's primary care medicine to be a future career option. The programme was academically evaluated by a final year medical student and showed that all student respondents would recommend the placement and that GMED was a welcoming and receptive learning environment with high quality teaching. Improved Drug Control Audit (GMED) 4.6 In November 2025, GMED completed an extensive review of its controlled drug policy in partnership with the NHSG Controlled Drug Team. Safe and compliant management of controlled drugs within the service present unique challenges due to GMED's multi location sites and large numbers of (often transient) clinicians. The policy is now up to date, approved and compliant. Widespread associated training has taken place across the service and all staff groups have contributed to making the changes needed to effect safe and compliant practice. Flow Navigation Centre (GMED) 4.7 In November 2025, GMED commenced a 3 month test of change (ToC) formalising support to the Flow Navigation Centre (FNC). The FNC serves to give senior clinical decision support to a variety of healthcare professionals operating in the community, including GP's, Advanced Nurse Practitioners (ANP's), SAS ambulance crews, Minor Injury Units, care homes, and the cancer support helpline, to name but a few. It also serves as a means to ensure patients are directed to the most appropriate service and location to meet their needs, consistent with the Right Care, Right Place, Right Time principle. The ToC has seen GMED staff the service between midnight and 8am during the week and from midnight on Friday through to 8am on Monday morning, with the weekend staffing enhancing the existing clinical support provided by the FNC team. This additional support has allowed a reliable and sustainable staffing model. With GMED already ideally placed within the primary and secondary care interface, it has seen timely and efficient delivery of service that has received excellent feedback, particularly from ambulance crews who use the service to ensure their patients are cared for in the most appropriate location for their needs. GMED and FNC have fostered an excellent working relationship and it has been agreed to extend the ToC for another 3 months. Page 33
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Moray Learning Disability Health Check Programme 4.8 In May 2022, the Scottish Government issued a directive requiring all Health Boards to provide an annual health check for adults aged 16 and over who have a learning disability. This national requirement placed a clear responsibility on Health Boards to ensure consistent, proactive delivery of these checks. 4.9 In response, HSCM developed and launched a pilot programme to explore an effective local delivery model. The six-week pilot involved 21 adults; identified based on their proximity to the chosen clinic location. The pilot aimed to test operational processes, engagement levels, and the feasibility of wider rollout. Findings demonstrated strong need and high willingness to engage when appointments were accessible, familiar, and well-supported. Following the successful pilot, a phased expansion was undertaken. Further details can be found at Appendix 2. Dietetics, Pharmacy and Health Visitors - Collaborative Working 4.10 Recently, a Primary Care Advanced Pharmacist, and a Specialist Pharmacy Technician, attended the annual Scottish Practice Pharmacy & Prescribing Advisers (SP3A) conference where they represented HSCM and the collaborative work that has been ongoing between Pharmacy, Dietetics and Health Visitors. The teams have been working together to review the prescribing of baby milk within HSCM with the aim of improving prescribing and reducing spend by adhering to existing guidelines. Through training, data sharing and re-launching the guidance, there has been a quarterly expenditure saving of £34,000 and parents/carers have been given clearer education on the appropriate use of baby milk and the milk ladder. This collaborative approach has helped to strengthen relationships across the multi-disciplinary team and support appropriate prescribing. Medication Management Procedure 4.11 An updated Medications Management Procedure was approved for use in November 2025 by the HSCM CCG Group. The updated document reflects current and relevant processes, legislation, and best practice guidance. The procedure contains information for health and social care staff about the safe ordering, handling, storage, management, administration, and disposal of medicines. The group noted the significant amount of work attributed to updating this document. Refresh of TORs / Workshop 4.12 Due to difficulty scheduling a time when all CCG Group members could attend, the planned workshop has been deferred until March 2026. The focus will be on refreshing the purpose and terms of reference of the group, ensuring that all members have a shared understanding of clinical and care governance, which will ensure consistency and appropriate reporting through to this Committee. NHS Scotland Risk Matrices 4.13 Healthcare Improvement Scotland (HIS) worked with NHS Territorial Boards to refresh the NHS Scotland Risk Matrix. The updated matrices were available for use from 10 November 2025. The new matrices retain the same five impact assessment / category and risk likelihood descriptors however a much more Page 34
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detailed descriptor is provided which supports risk handlers and owners to consider the impact of their risk. All risk handlers have been asked to review risks on the operational and sector risk registers in line with the new Risk Matrix. HSCM Duty of Candour Guide 4.14 As previously reported, a local improvement plan was developed to strengthen understanding and reporting of Duty of Candour (DoC) following a review of incident reporting, which assessed the accuracy, completeness, and overall quality of documentation. The group welcomed the updated guidance on the management of DoC. This guidance, drafted through the Clinical Risk Management (CRM) group, is intended to support staff in making consistent and informed decisions regarding DoC and to increase confidence in their decision-making processes. Overview of Incidents, Complaints and Risk Management Clinical Risk Management (CRM) 4.15 The CRM group continues to meet every 2 weeks to discuss issues highlighted on the HSCM Datix dashboard. This includes Level 1 and Level 2 investigations, Complaints, DoC and new, Very High and High Operational Risks. 4.16 The group is attended by members of the Senior Management Team, Clinical Leads, Chief Nurse and relevant Service Managers. The purpose is to provide assurance to senior leaders regarding the quality and standards of services. The group ensures that adverse events and complaints are investigated appropriately, and learning is identified and shared across the organisation. 4.17 Any learning identified is presented and discussed at all relevant operational meetings, including cross sector where applicable. Complaints and Feedback 4.18 The HSCM Quarterly Complaints report for Quarters 1, 2 and 3 of 2025/26 is a separate item on today’s agenda. Adverse Events (AE) 4.19 Information about AE reported on Datix during Quarter 3, 2025/26 is available at Appendix 3. 4.20 Graph 1 in Appendix 3 shows that while figures remain relatively consistent there are three peaks noted at Q3 2022/23, Q3 2023/24 and Q2 2025/26 for adverse events that resulted in no harm. The increases can be attributed to our mental health inpatient areas. Some inpatients can display higher levels of distress, violence and aggression, and this results in more recorded incidents. In addition, during Q2 2025/26 there was one inpatient in a Community Hospital that attempted to abscond multiply times a day; each incident was recorded on Datix. Findings and Lessons Learned from incidents and reviews 4.21 A Level 1 review consists of a full review team who have been commissioned to conduct a significant event analysis and review, reporting findings and learning via the division/service governance structures. Page 35
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4.22 There are currently 12 Level 1 reviews in progress (at the time of reporting). One Level 1 review have been closed in this reporting period. Timeframes for Level 1 reviews is set out in the table below: Commissioning L1 review once the adverse event is reported within 10 working days Commence, close the review and submit report for approval within 90 working days of commission Final report approval within 30 working days of report submission Develop an improvement action plan within 10 working days of final report approval 4.23 All 12 Level 1 reviews in progress are overdue for the stage they are at. 4.24 NHS Grampian have set up a short life working group (SLWG) to improve performance on Level 1 reviews. The Chief Nurse for Moray is part of this workstream and will provide updates to committee members through this report going forward. HSCM Risk Register 4.25 Each Clinical service/department highlights risks associated with their service. Service managers are invited to join CRM who offer constructive challenge and support. These discussions ensure risks are being appropriately reviewed, mitigations are in place and records are accurate and up to date. 4.26 The risk register is routinely reviewed with leads with guidance and support provided regarding updates. A review of all internal processes associated with risk registers is about to commence and any relevant updates will be taken through the appropriate governance structures. 4.27 At the time of reporting, there are 32 risks on the sector risk register. These are monitored and reviewed as appropriate, by the service managers. The current risk level of each risk is displayed in the chart below: Low 3% Medium 66% High 25% Very High 6% Risks by Risk level (current) Low Medium High Very High Page 36
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4.28 A number of operational risks are assessed as High and Very High, predominantly relating to workforce pressures. These risks are being actively managed and overseen through established HSCM governance arrangements, including the CRM Group. At present, no operational risks require escalation to this Committee. Duty of Candour (DoC) 4.29 DoC incidents are unintended or unexpected incidents that result in death or harm as defined in the Act, and do not relate directly to the natural course of someone’s illness or underlying condition. 4.30 There were 3 confirmed organisational DoC events for the year 1 April 2024 to 31 March 2025. Items for escalation to the Clinical and Care Governance Committee General Practice Sustainability 4.31 A briefing, prepared in line with the action recorded at September 2025’s MIJB meeting, addressing specific issues escalated by this Committee following their meeting on 28 August 2025, was circulated to MIJB on 7 November 2025. This was followed up by a formal report to MIJB at their meeting on 27 November 2025 (para 10 of minute refers). A more detailed report on the development of mental health services across the wider Moray health and social care system (aimed at reducing pressures on primary care) will be presented to the MIJB on 26 March 2026. A follow up report is scheduled to be presented to this Committee on the 28 May 2026. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the HSCM Senior Leadership Team and to this Committee. There are platforms within Health and Social Care to discuss and share good practice, learning and challenges. Page 37
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Moray Integration Joint Board (MIJB), Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. Adverse events and complaints provide significant information on trends relating to risk and an encouraging opportunity for learning across the system. Regular monitoring of this is critical to ensure continuous improvement and the ambition of achieving excellence in our delivery of high quality care and treatment. The local CRM group reviews all events logged on Datix, ensuring risk is identified, managed and reviewed accordingly. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. (f) Property None directly arising from this report. This report does not propose any changes to physical infrastructure. (g) Equalities/Socio Economic Impact There is no requirement for an equality impact assessment because there is no change to policy required as a result of this report. (h) Climate Change and Biodiversity Impacts None directly arising from this report. This report focuses on clinical and care governance, specifically relating to service quality, safety, and learning from adverse events and complaints. (i) Directions None directly arising from this report. This report does not propose any changes to physical infrastructure, service delivery models, or resource allocation. (j) Consultations Consultations have been undertaken with the following staff who agree with the content of this report where it relates to their area of responsibility: • HSCM Clinical and Care Governance Group members • Sonya Duncan, Corporate Manager • Caroline O’Connor, Committee Services Officer, Moray Council • Bridget Coutts, Lead Nurse GMED • Lisa Taylor, Health Improvement Team Lead – Moray • Cheryl St Hilaire, Locality Manager Page 38
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• Marie Burnell, Integrated Service Manager, Learning Disabilities • Alistair Boyd-Orr, Lead Pharmacist Primary Care 6. CONCLUSION 6.1 The HSCM CCG Group are assured that issues and risks identified from complaints, clinical risk management, internal and external reporting, are identified and escalated appropriately. The group continues to develop lines of communication to support the dissemination of information for action and sharing of good practice throughout the whole clinical system in Moray. This report aims to provide assurance to this Committee that there are effective systems in place to reassure, challenge and share learning. Author of Report: Isla Whyte, Corporate Business Support Manager, HSCM Background Papers: with author Ref: Page 39
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APPENDIX 1 Realistic Medicine and MeOC Benefits Realistic Medicine is about finding out what matters most to the people we care for. This helps to deliver care that is valued and makes a difference. It also reduces waste and harm from unnecessary or unwanted treatment. The Health Improvement Team support the wider NHSG Realistic Medicine programme. We champion values based care across Moray, through delivery of reflective sessions with HSCM teams to build awareness of how the principles link to their practice. The sessions particularly encourage all health and social care practitioners to: • Have conversations about what matters most to people • treat people as an equal partner • share treatment decisions, supporting informed choices The Making every Opportunity Count approach is also promoted within these sessions which are routinely delivered across Health and Social Care Moray including third sector partners. Sessions also form an element of the Moray Council Care at Home Induction programme. In total 333 practitioners have undertaken this training session giving positive feedback and sharing practical examples of implementation. Realistic Medicine and MeOC both align and compliment the GIRFE principals. The projects are included within the Home First work stream and Partners in Care. Practitioner Benefits • Enhanced Person-Centered Care: Promotes 'What Matters to You' conversations and shared decision-making, ensuring care aligns with patient values. • Improved Professional Skills: Training in Shared Decision Making, MeOC enhances self- reported confidence in having conversations. • Streamlined Care Delivery: Tools such as Ageing Well support to reduce unnecessary interventions through promotion of self-management. • Professional Reflection and Continuous Improvement: Encourages reflection and adoption of value-based care approaches through changing the way we have conversations. Practitioner Feedback following awareness sessions: “It’s important to empower people so that they can make informed choices in their lives with the help of professional staff.” "I feel more able to equip people to understand and articulate their own views" "These are useful resources to ensure I am aware of more service that may support patients and I can include people in managing their own care" “The Ageing Well Tool gives patients a resource to consider their health in their own time, as people can be overwhelmed during a consultation.” Page 40
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Patient Benefits • Empowerment and Involvement: Patients are actively encouraged to be involved in decisions, improving satisfaction and outcomes. Campaigns such as ‘It’s ok to ask’ are promoted locally. • Prevention and Early Intervention: The approach focuses on upstream prevention and early detection aiming to reduce hospital admissions and increase independence. • Improved Access to Support: Self-check signposting tools connect patients to availble community resources. • Realistic Medicine fosters a culture of person-centred, value-based care supporting sustainable health and wellbeing outcomes. Patient feedback: “Really good, provides useful information about services. When you go to the GP, you don’t get this information.” “I was given a self-check when I was at A&E with my husband – it's great!” “I’m glad you talked about It’s Okay to Ask. I’m going to go and ask my doctor about the side effects of a medication I’m on.” Community Appointment Day (CAD) The aim of a CAD is to move away from treatment led approaches, towards person centered and value based care. Realistic Medicine principles were applied throughout the Musculoskeletal CAD journey. Evaluation found that the ‘what matters to you’ conversation was a valuable component of the day with 80% of attendees finding it useful. The following patient quotes again highlight the value in shifting towards value based care approaches: “It helped me to be directed to the right service and support” “It helped me to think about what other different services would help, not specifically for my condition, other things that could help me, with other things happening in my life”. Risks The current team driving forward Realistic Medicine and MeOC in Moray are on fixed term contracts which will end on 31 March 2026. The contingency plan to transition delivery to Healthpoint Advisors is not viable under current conditions. Due to vacancy control measures, the Healthpoint team is operating at approximately 50% capacity, which significantly limits the ability to undertake additional responsibilities while maintaining core Healthpoint service delivery. Without recruitment to fill Healthpoint vacancies, the continuation and sustainability of the Realistic Medicine and MeOC work stream will be at significant risk in 2026/27, potentially limiting progress toward strategic objectives. Page 41
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APPENDIX 2 Moray Learning Disability Health Check Programme Programme Rollout Following the successful pilot, a phased expansion was undertaken. Key elements included: • Recruitment of a dedicated part-time nurse to deliver the checks. • Partnership working with GP practices across Moray, who provided clinic space and local support. • Flexible delivery approaches, including home visits for individuals unable to attend surgeries. This collaborative approach has supported delivery in settings familiar to individuals and carers, reducing barriers and promoting equity of access. Activity and Performance To date, the programme has achieved significant progress: • 295 health check offers issued (450-500 eligible people, still 85 to be offered and remainder have declined). • 223 health checks completed • Uptake rate: 75.6% This high level of engagement reflects the value placed on the service by individuals and families, and the commitment of the team and partner practices. A robust governance framework is embedded, with monthly review meetings focusing on performance, quality, outcomes, and continuous improvement. These reviews ensure that delivery remains safe, effective, and person-centred. Issues Arising Scheduling and Capacity Increasing demand has placed pressure on available appointment slots. Expansion of capacity is required to maintain timely access. Accessibility Home visits remain essential for those with complex needs or limited transport, but they are resource-intensive and require ongoing planning. Communication and Consent Ensuring that information is accessible and understood often requires additional time, personalised communication tools, and close collaboration with carers. Follow-Up and Coordination Many health checks result in multiple referrals (e.g., audiology, respiratory). Coordination across services can be complex and requires clear pathways and monitoring. Page 42
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Engagement with GP Practices GP practice support is crucial, but capacity pressures within primary care sometimes impact room availability and scheduling flexibility. Data Management Accurate and timely data capture is essential for monitoring uptake, outcomes, and follow-up actions. This remains an area requiring continued oversight and system improvement. Case Example A recent health check identified concerns regarding a person’s inhaler technique and potential hearing impairment. As a result: • A hearing assessment was arranged, confirming hearing loss. • Hearing aids were provided, significantly improving communication and wellbeing. • A respiratory clinic appointment was secured to review and optimise inhaler use. This case illustrates the programme’s impact in identifying unmet needs, supporting early interventions, and enhancing health and quality of life for individuals with learning disabilities. Lessons Learned Key learning to date includes: • The importance of early identification of health needs. • The need for accessible communication tailored to individual needs. • Value of strong relationships with GP practices. • Benefit of flexible delivery approaches, including home visits. • Critical role of regular review, staff training, robust governance, and effective follow-up. • Importance of trust-building with individuals, families, and partner services. Next Steps The team is preparing to launch Phase 2, which will focus on delivering follow-up health checks for individuals who have completed their initial assessment. This will strengthen continuity of care and embed proactive health monitoring as a routine element of support for adults with learning disabilities in Moray. Key priorities for the next phase include: • Expanding appointment availability • Sustaining strong collaboration with GP practices • Enhancing data systems to support governance • Ensuring equitable, person-centred access across Moray Conclusion The Moray Learning Disability Health Check Programme has demonstrated clear and measurable success since its inception. Strong uptake, effective partnership working, Page 43
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and commitment to continuous improvement provide a solid foundation for further development. As the programme moves into its next phase, it will continue to play a vital role in improving health outcomes, reducing health inequalities, and promoting equitable access to healthcare for adults with learning disabilities across Moray. Page 44
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APPENDIX 3 Adverse Events by Category and Level of Review Reported on Datix (Quarter 3, 2025/26) Table 1 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review No Level of Review Assigned Total Abusive, violent, disruptive or self-harming behaviour 72 2 0 11 85 Access, Appointment, Admission, Transfer, Discharge (Including Absconders) 9 4 0 4 17 Accident (Including Falls, Exposure to Blood/Body Fluids, Asbestos, Heat, Radiation, Needlesticks or other hazards) 87 1 0 32 120 Clinical Assessment (Investigations, Images and Lab Tests) 1 0 1 1 3 Consent, Confidentiality or Communication 7 0 0 4 11 Diagnosis, failed or delayed 1 0 1 1 3 Financial loss 1 0 0 1 2 Fire 5 0 0 0 5 Implementation of care or ongoing monitoring/review (inc. pressure ulcers) 13 0 0 3 16 Infrastructure or resources (Staffing, Facilities, Environment, Lifts) 9 0 0 4 13 Medical device/equipment 1 0 0 0 1 Medication 52 0 0 16 68 Occupational Disease 1 0 0 0 1 Other - please specify in description 27 0 0 6 33 Patient Information (Records, Documents, Test Results, Scans) 10 0 0 3 13 Security (no longer contains fire) 1 0 0 1 2 Total 297 7 2 87 393 Page 45
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Adverse Events by Type and Result Reported on Datix (Quarter 3, 2025/26) Graph 1 0 20 40 60 80 100 120 140 160 180 200 Adverse Events by Type and Result Near Miss (event prevented) Event resulted in NO injury, harm or ill-health Event resulted in injury, harm or ill-health Page 46
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Adverse Events by Service and Level of Review Reported on Datix (Quarter 3, 2025/26) Table 2 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review No Level of Review Assigned Total Allied Health Professionals 10 0 0 0 10 Community Hospital Nursing 58 5 0 43 106 Community Nursing 28 0 0 5 33 Community Pharmacy 1 0 0 0 1 General Practice 2 0 0 1 3 GMED 23 0 2 19 44 Grampian Vaccination and Immunisation Programme 51 0 0 2 53 Mental Health - Adult Mental Health 36 2 0 11 49 Mental Health - Learning Disabilities 1 0 0 0 1 Mental Health - Old Age Psychiatry 76 0 0 1 77 Mental Health - Specialisms 3 0 0 3 6 Primary Care 4 0 0 0 4 Public Dental Service 4 0 0 0 4 Public Health 0 0 0 2 2 No value 0 0 0 0 0 Total 297 7 2 87 393 Page 47
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Adverse Events by Type and Severity Reported on Datix (Quarter 3, 2025/26) Table 3 NEGLIGIBLE: Negligible/no injury or illness, negligible/no disruption to service, negligible/no financial loss MINOR: Minor injury or illness, short term disruption to service, minor financial loss MODERATE: Significant injury, externally reportable e.g. RIDDOR, some disruption to service, significant financial loss MAJOR: Major injury, sustained loss of services, major financial loss EXTREME: Death or major permanent incapacity, permanent loss of service, severe financial loss Total Breach of Information / IT Security 5 0 0 0 0 5 Patient / Client / Resident 213 59 1 0 1 274 Staff (including Volunteers) 14 6 0 0 0 20 Student or Trainee 1 0 0 0 0 1 Visitors, Relatives or member of the Public 3 1 0 0 0 4 Provision of Service 27 2 0 1 1 31 Audit 1 0 0 0 0 1 Property / Equipment 53 2 0 0 0 55 Issue for discussion at M&M or Risk Man. mtg 1 0 0 0 0 1 Inadequate Discharge 1 0 0 0 0 1 Total 319 70 1 1 2 393 Page 48
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Table 4: All adverse events by result by Quarter (Qtr) on Datix 2022/23 Qtr 3 2022/23 Qtr 4 2023/24 Qtr 1 2023/24 Qtr 2 2023/24 Qtr 3 2023/24 Qtr 4 2024/25 Qtr 1 2024/25 Qtr 2 2024/25 Qtr 3 2024/25 Qtr 4 2025/26 Qtr 1 2025/26 Qtr 2 2025/26 Qtr 3 Occurrence with NO injury, harm or ill-health 283 200 210 270 327 235 217 225 252 275 272 340 270 Occurrence resulting in injury, harm or ill-health 78 60 73 76 71 70 69 59 70 79 99 96 78 Near Miss (occurrence prevented) 38 20 22 26 50 31 27 41 30 44 36 46 45 Property damage or loss 0 0 0 0 0 0 0 0 0 0 0 0 0 Death 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 349 280 305 372 448 336 313 325 352 398 407 482 393 Page 49
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Table 5: Adverse Events by Severity Reported by Quarter (Qtr) on Datix 2022/23 Qtr 3 2022/23 Qtr 4 2023/24 Qtr 1 2023/24 Qtr 2 2023/24 Qtr 3 2023/24 Qtr 4 2024/25 Qtr 1 2024/25 Qtr 2 2024/25 Qtr 3 2024/25 Qtr 4 2025/26 Qtr 1 2025/26 Qtr 2 2025/26 Qtr 3 Negligible 283 226 240 305 388 274 256 278 294 329 325 401 319 Minor 60 48 58 61 52 53 50 43 56 66 79 74 70 Moderate 5 6 5 6 8 9 6 3 1 1 3 4 1 Major 0 0 1 0 0 0 1 1 0 0 0 0 1 Extreme 1 0 1 0 0 0 0 0 1 2 0 3 2 Total 349 280 305 372 448 336 313 325 352 398 407 482 393 Page 50
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Graph 1: All Adverse Events by Result per Quarter 0 50 100 150 200 250 300 350 400 Q4 21/22 Q1 22/23 Q2 22/23 Q3 22/23 Q4 22/23 Q1 23/24 Q2 23/24 Q3 23/24 Q4 23/24 Q1 24/25 Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26 Q3 25/26 All Adverse Events by Result per Quater No harm Harm Near Miss Page 51
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