Governor Questions Log

No.	Date	Governor	Query	Response	
198	28 May
2025	Paul Williams	In response to a query regarding the antenatal screening incident that had identified 37 women that had not received antenatal screening, the Chair of the Quality Committee advised that the antenatal screening incident was high profile, and the Regional & National team were visiting the Trust. It had been identified that there are staff shortages within the ultrasound team, and the high volume and cost of agency staff had been addressed.	There was a serious antenatal screening incident which was fully investigated. The incident involved the first trimester scan provision and additional ultrasound scans were put in place with support from the region. All actions have been completed and the trust is expecting the national screening team to visit shortly. This will provide robust external assurance for the board.	
199	22 July
2025	Sunila Lobo	The provision of safe and high quality patient care is an absolute priority for the trust and all our clinicians work to rigorous protocols to ensure patient safety’.
Patient welfare is the Trust’s responsibility. Yet, there have been serious incidents at the Trust. On behalf of the community, governors are seeking assurance that
internal governance	Extensive work has been carried out by the Trust both prior to, and following, the issue of the PFD notice in April to both strengthen and streamline our mortality and learning from death processes within surgery.

These changes include:

Providing additional support for the surgical team to ensure adherence to the Trust’s mortality and learning from deaths processes to capture information for use in departmental mortality and morbidity and clinical governance meetings.
Revising General Surgery’s Structured Judgment Review (SJR) process to ensure reviews are conducted by consultants with the same subspecialist interest, followed by a second review by another surgeon before sign off by both surgeons. Additionally, a parallel	

			processes and protocols are being reviewed with urgency, for improvement, especially around Serious Incidents, Never Events and Mortality. Please can you describe the outcome of this detailed review/investigation and steps taken to reduce or eliminate re-occurrence?	anaesthetist-led SJR has been introduced to provide diverse perspectives.

We have also instigated and are embedding a number of changes to our Trust processes for capturing learning and preparing for inquests when parallel review processes are being undertaken. A detailed summary overview of the case is now generated including timelines of the patient's clinical journey; key diagnoses treatment; circumstances of deterioration and death; reviews and actions undertaken; learning points; concerns around avoidability and preventability; communications with the family and an indication to the Coroner about the status of all reviews and whether they are complete or ongoing.

We have also, as part of ongoing work with the Coroner, implemented an Inquest Disclosure Checklist to ensure clarity and completeness.

The changes we have made will ensure teams adhere to our learning from deaths processes and are more easily able to extract relevant learning from cases. There would also be greater clarity for the coroner and patients’ families of the processes followed and any changes instigated as a result of our learning.

The surgeon stopped performing major colorectal surgery in June 2024 and ceased all other surgery in September 2024. He continues to work at the Trust focusing on outpatient work; adhering to restrictions and conditions imposed by the GMC. His safety record within his current scope of practice has been reviewed and no concerns found.	

200	2 June
2025	Sunila Lobo	The issue of audibility of the calling of names at the A&E waiting room has been brought up by members of the public and mentioned at Public Board too. This is particularly concerning for those with hearing loss as well as other hidden disabilities such as autism, anxiety or phobias.
Further, the fear of missing a call-out creates added anxiety. Could tech, for instance, as used in GP surgeries
or restaurant table buzzers be a solution to this issue?	The team make a huge effort to ensure that the patient does not miss being called. As mentioned in our previous response, the team call the patient numerous times. They call from the triage door, they will go out to the waiting room to call the patient and they will also go outside the front of the department to call the patient. This will happen 4 times.

We have not had many PALS and complaints and certainly none recently about the fear of missing being called or delayed treatment due to missing being called. Due to the nature of the department, buzzers such as those used in GP surgeries wouldn’t be suitable. For those patients who are deaf/heard of hearing this would be identified at booking in and a note made on the system to alert the member of staff calling the patient.	
201	12 June
2025	Sunila Lobo	UCC from Broad Street Mall to RBH from 1 July 2025: The question is whether patients are able to walk-in to UCC as they used to at Broad Street Mall or only if they are directed by NHS 111 there or through triage at RBH’s A&E? When will this be made clear?	The service has been commissioned by the ICB and patients can either be;
1.	Redirected by primary care when they reach capacity
2.	Via NHS111
3.	Redirected by ED triage/streamer
4.	Walk in
The ICB are running the communications, and have tried to focus on patient’s using NHS111 to ensure they are redirected to the most appropriate service. We have set up a Trust webpage for patients to better understand the criteria and access routes: Reading Urgent Care Centre	

202	25 June
2025	Paul Williams	When organisations are dependent on digital systems, and with hacking becoming popular, public sector organisations are implementing backup data centres and sharing data centres.

Does the NHS Trusts within BOB share data centres for security, backup and
economic reasons?	At present, the NHS trusts within BOB do not share data centres for security, backup, or economic reasons. Each trust is responsible for managing its own infrastructure with resilience and recovery arrangements in place. However, shared data centre options are currently being explored as part of wider digital strategy discussions.	
203	25 June 2025		The Trust had received capital funding for a new LINAC machine and the Trust was required to fund the installation costs from its own capital expenditure.  Therefore, this was a high priority for the capital programme 2024/25, was the Trust now required to finance the annual maintenance and servicing costs.	The Trust was already paying annual service and maintenance costs for the existing LINAC machine.  Therefore there is no additional cost being incurred. 	
204	5 August
2025	Richard Havelock	I understand that there a recent incident during the night on a general surgical ward in which a quadriplegic patient was disconnected from supporting medical equipment by another patient with dementia whose bed was adjacent. What measures are taken to prevent patients with dementia on general wards from interfering, albeit inadvertently, with equipment providing essential support to other patients?	For all our patients we use “Enhanced Therapeutic Observations of Care” (ETOC). This is a method of providing supervision, support and engagement with patients. All patients regardless of their ward location will be assessed in the same way.
The decision to use ETOC is based on a risk assessment which is carried out on the patient’s physical or mental state. The risk assessment must be repeated at least once a shift or when a change in condition occurs. This should be used in conjunction with the safer nursing care tools (SNCT) acuity and dependency levels tool. There are multiple reasons why a patient might require ETOC e.g. acute mental illness, risk of falls, agitation/confusion/aggression. The levels of ETOC are rag rated dependant on need e.g. red requires continuous observation or 1:1 within arm’s reach. The level of enhanced care observation must be proportional (least restrictive) to risk to self or others. In some cases a patient may be assessed and deemed safe to have 30 minutes nursing observation safe and seen (Green low level of enhanced observation) because they are not attempting the wander despite confusion. If however, their condition changes and they do start to become more confused, wander or become agitated their repeated risk assessment could show they require 1:1 within arm’s reach enhanced observation.	

205	19 Aug
2025	Alice Gostomski	The Orthopaedic department routinely has appointments up to 5pm and many patients attending these have mobility issues.
Governors have previously asked whether there is any possibility of extending the time of the Buggy being available and many of the Buggy drivers have stated they would be happy to extend the
service to 5pm.	
The Trust reviews the buggy service annually looking at usage and feedback. However, we have taken on board this query, and have undertaken an audit with our buggy drivers, outpatient clinic receptions and the complaints department. 

The results of this were overwhelmingly positive and without any concerns being raised from patients and the clinic areas.  It was identified that OPD’s prioritised patients requiring the buggy on the clinic lists.

Out of 30 buggy drivers audited, 8 felt they would like to trial a later finish, which we will plan for the new year as this will require complex session and shift change planning, how drivers will be called and staff support.

206	22 Aug
2025	Miranda Walcott	
Constituents from Reading and Wokingham’s Children and Young People Me2 club, have asked if the hospital have plans to address the waiting rooms, as they can cause anxiety, for children and young people who have a Special Educational Need and/or Disability.
This is due to knowing they will have to wait, and there is a wide range information about health problems in the waiting rooms which can cause a challenge for or young people with additional, some who may
already have health anxiety?	
The Trust continually strives to meet the Royal College of Paediatrics and Child Health guiding principles for the delivery of care to children and young people in hospital settings.  These principles recommend that audio and visual separation with additional play resources are available for all ages of children and young people (CYP).  

We see and treat children in outpatient settings in several locations across our sites in order to meet the accessibility needs of our local population.  We have also reviewed our outpatient services across all our sites and have improved the play facilities for children and young people. 
 
We recognise that our Emergency Department (ED) can be a very daunting environment for children and young people, especially for those with additional needs.  We have recently developed a paediatric Same Day Emergency Care (SDEC) pathway that enables some of our children and young people requiring urgent treatment to be cared for in a dedicated area away from ED which is a quieter and calmer environment.  This new pathway also means that many children will wait for less time to receive the care they need in both Emergency Department (ED) and the Same Day Emergency Care (SDEC) areas.

Overall, and in alignment with our Children & Young Person Strategy, the Trust is committed to improving the experience of our children and young people (CYP) under our care and all of this work is overseen by the Care Groups and the Children and Young People (CYP) Steering Group that is chaired by the Chief Nursing Officer.

	
207	10 Sept
2025	Adrian Mather	A number of recent cyber- attacks are likely due to weak		

			password security e.g. short passwords and or sharing of passwords.
Please describe RBH password security and any measures which are being proposed to increase password security. FYI my employer requires 14 character passwords.
Typically there is weaker security on non-production data centres / systems / applications. Please describe any differences between non- production and production environments. Please note that “small” applications which may be owned or administered by front line teams may have weaker security than mainstream systems.	Regarding the inquiry about environments (point 2), we do not maintain a separate development environment; therefore, all systems reside in the production environment and are subject to the same security policies.
The core of this question, however, appears to be about enforcing policy on systems that don't use Active Directory (AD) authentication.
Policy Compliance for Non-AD Systems
We can enforce policy on systems that are capable of non-AD authentication but not on those that are fundamentally unable to do so. In cases where the system cannot enforce the policy automatically, the Information Asset Owner (IAO) is responsible for ensuring compliance with all relevant policies.
This distribution of responsibility is formally defined in the "Roles and responsibilities" section of document CG099:
Information Asset Owners - All assets should have a designated Asset Owner. 

Asset owner responsibilities include:
•	Ensuring information and information assets are appropriately classified; 
•	Ensuring that employees understand security policies, procedures, and responsibilities in relation to the asset;
•	Approving appropriate data access, allowing staff to complete business-related tasks; 
•	Defining and periodically reviewing access restrictions and classifications, taking into account Information, Data Asset & Risk Management Policy 
•	and IT Systems Access, Remote Access and Electronic Communications Policy, as well as applicable access control procedures and matrices; 
•	Defining appropriate data retention, storage and handling requirements; 
•	Reviewing, evaluating, and responding to all security violations reported against employees, and taking appropriate action; and 
•	Communicating in accordance with local procedures when employee departures, arrivals, and changes affect computer access.	
208	10 Sept
2025	Tom Duncan	I declare an interest as I sit on a clinical data committee, for which I have one hour of job- planned time per week.
Despite the Trust’s investment in the Cerner EPR, clinicians and committees currently have less access to usable clinical
data than we did 10 years ago.	The Trust is currently revamping the Trust Strategy and, in tandem, updating our digital strategic plan to better align with our strategic ambitions.  Through a series of engagement workshops and feedback sessions, we have pinpointed "access to real-time data for quick decision-making" as a key theme for our digital strategic roadmap. We are dedicated to developing a local strategy, supported by the wider system and regional data stores, to provide clinicians, patients, and service users with the necessary information for analysis, future planning, or real-time status updates.  Additionally, we are focusing on data security policies to ensure that data is never shared or displayed inappropriately.

			Many experienced analysts have left, Cerner DA2 is unsupported, and existing dashboards are not being maintained. Although the Health Data Institute is in theory available for internal work, in practice its funding and governance arrangements make access overly complex.
As a result, clinicians are often reduced to manually extracting small samples from individual records into spreadsheets, when we should be able to analyse thousands of records to drive quality improvement, audit, and operational learning.
What assurance can the Board give that there is a coherent strategy and sufficient investment to maintain existing dashboards, simplify access to the HDI, and develop reliable, clinically useful data and analytics to support internal audit, quality improvement,
and operational decision- making?
		
209	10 Sept
2025	Tom Duncan	For several years I have raised the issue of smoking on Trust premises. Despite repeated
promises of action, staff and	The Trust is committed to all our sites being smoke free and this has been evidenced through signing the smoke free pledge and updating our smoking policy (Smoke Free Policy, CG577). 

			visitors continue to smoke in stairwells and directly outside office windows, forcing staff to keep windows shut in summer. Engagement exercises, signage, and commitments made over two years ago have not led to meaningful change.
How are NEDs assuring themselves that the Trust’s smoke-free site policy is being properly enforced, what evidence will they require to be confident it is effective, and by when will this assurance be reported back to the Council of Governors, given how long this
issue has been outstanding?
	Focused improvement work has been in place for over 18 months and this relates to signage, leadership walk arounds, staff & patient health checks and engagement with our partners at smoke free life Berkshire to have continual presence on our sites for patients and staff.  
When incidents have been raised these have been taken seriously and acted upon.  
We continue to move forwards and take this seriously as part of our role as a health promoting hospital and in relation to the 10-year health plan with the shift to prevention.  This is an area of improvement work that requires everyone’s engagement, support as well as a compassionate coaching style approach to conversations and signposting.   We continue to be open to working together and hearing new ideas to help address this area of improvement. 
	
210	2 October 2025	Darren Browne/
Maria Norville	Can clear signage be displayed in the ED reception for patients with neurodiversity and additional needs?

Can staff use AI application to support pronunciation of patient names?

Can the screen already in situ in A&E be used to provide information about the hospital as well as flash up patient names - just like GP surgeries do?  What is the cost of the software needed? If it is not affordable in 2025/26 can it be budgeted for 2026/7?	The Chief Nursing Officer completed a spot check in the area. 10 different staff members were observed across different staff groups and they all practised in a very similar way.  

The issue of pronunciation could be an issue anywhere in the Trust & staff will try their best to use the correct name, we obviously work as part of a diverse team so teams will be supporting each other to ensure they use the correct pronunciation. 
Only one complaint had been received to date in relation to pronunciation of names although this complaint also included broader care concerns.
The speed at which patients were being called through was also significant – 21 patients in 35 minutes.  We would have to equally be mindful if there was a tanoy style system (I know we are considering patient portal options too) that this would not cause excessive noise and we would need to consider that for neurodiversity and also those with physical health symptoms, eg headaches etc.. A tanoy with no noise and just names flashing up is another option, but due to the size of the area and the central pillar this would also not be a total failsafe.

Chief Nurse’s overall response was that the suggestions had been received and referred to the Digital Data and Technology (DDaT) team for wider review across the Trust.
	
211	13 November 2025	Clive Jones	Can we find out if these problems with the new system Medisight can be addressed? What is the cost to get it working properly? Are any other parts of the hospital using the system for their appointments? What was the cost of replacing the system?
	The mediSIGHT system is an Ophthalmology specific EPR that went live on 1 September 2025 and is an upgraded version of our previous ophthalmology EPR, which was no longer supported and had significant ongoing support costs. We are aware that there have been some teething issues with the new system, which are being worked through with the Digital, Data and Technology (DDaT) team, along with support from the software provider and the department.
Whilst Ophthalmology clinics have been operating at reduced capacity while this work has been ongoing, clinic numbers have been increasing, and a plan is in place to return to full capacity from 1 December 2025. 	
212	7 January 2026

22 January 2026	Tom Duncan 	What gritting was done of staff car parking spaces in preparation of a yellow ice warning for 7 January 2026

Why have we got paint on there that creates a slip hazard in cold weather?

What reviews have taken place and what does ‘accordingly’ mean in terms of monitoring?

How many incidents were reported? 

Have there been any cases of staff sustaining injuries such that they are now missing work?

What time were the gritting team attending the site and what time are they attending now after the update?
	Gritting is taking place at the appropriate frequency and in line with the information we receive from the Met Office. Decisions are based on road surface temperatures rather than air temperature. Current trigger point is 0.5 Road Temperature, which has been the agreed trigger point for a number of years.
We are aware of reported slips and falls across the estate this week. The majority of incidents occurred on painted road markings in car parks (particularly pedestrian crossings) and on Level 2 of the multi-storey car park, which is an exposed area. These locations have been reviewed and monitored accordingly. Significant rainfall overnight washed away the grit that had been applied, followed by a rapid drop in temperature which resulted in freezing conditions.  Met Office reports are issued daily whenever there is a risk of low temperatures. These are actively monitored, alongside weather forecast applications, to provide guidance for the week ahead and to ensure additional measures are implemented during severe weather warnings, including the recent yellow alerts.
The unpredictable and rapidly changing weather conditions over the past week highlighted several challenges. In particular, there were occasions where rainfall washed away grit shortly before freezing conditions set in.  As a result the estates team had discussed these issues with the gritting team, who have agreed to attend site earlier in the mornings when these conditions occur, weekend coverage has been reinforced to ensure consistent protection and daily walks have been implemented to provide assurance all areas have been gritted and are safe, when temperature drop.

The paint used is thermoplastic paint, which is standard across roads, highways, parking areas, and similar external surfaces and is used across the country by all councils. 

A new risk assessment has been completed for the Multistorey Care Park by our Health & Safety team. “Accordingly” refers to the actions taken following this review.

8 incidents have been reported

Yes, 2 cases. Both from the 7 January 2026 when we had the rapid freeze after the rain.

Previously, the gritting team attended the site on the afternoon prior to the predicted trigger point. For example, if the trigger point was forecast for 04:00 on Wednesday 28/01/26, the team would grit the site between 12:00 and 16:00 on Tuesday 27/01/26 and then revisit the affected areas from 08:00 on Wednesday 28/01/26.
Following the update, the team will continue to prepare all areas the afternoon before. However, if the trigger point is forecast for 04:00, the team will now attend the site again at approximately 05:00 to check all areas, completed again before the main hospital ingress and egress period between 07:00 and 09:00	
213	9 January 2026 	Darren Browne 	From April 2026, HMRC will apply strengthened “joint and several liability” rules for employment taxes. Where agency or umbrella arrangements are found to be non-compliant, HMRC may recover unpaid PAYE and National Insurance from any party in the supply chain, including the NHS Trust as end-hirer. Importantly, worker tax indemnities used by some agencies do not protect the Trust from HMRC action.
Given the Trust’s reliance (although reducing) on temporary and agency staff, this presents a material governance, financial and reputational risk if not properly thought through.

My submission asks to consider whether the Trust should:
•	Use agencies that only operate through umbrella payroll companies holding FCSA accreditation, and
•	Consider requiring that each agency worker timesheet and corresponding payment is independently audited through a product such as SafeRec, which provides real-time, auditable assurance that PAYE and NICs have been correctly applied.

These measures would give the Trust independent, defensible oversight of payroll compliance across its labour supply chain ahead of the April 2026 commencement date.	The Trust recognises the importance of the forthcoming HMRC changes and the need to maintain appropriate oversight of employment tax compliance across its labour supply chain. The Trust’s policy is to source temporary and agency staffing exclusively through nationally approved NHS procurement frameworks. Agencies appointed through these frameworks are subject to due diligence, including assessment of their understanding of, and compliance with, relevant tax and employment legislation, and are required to provide appropriate contractual assurances. 
In relation to payment assurance, the Trust has established internal controls requiring verification and approval of shifts worked prior to payment being processed. These controls are designed to ensure that payments align with authorised work undertaken. 
The Trust continues to review its arrangements in response to regulatory developments; however, at this time we do not consider that the introduction of an additional external audit layer for agency worker timesheets and payments is necessary. The position will remain under review as further guidance becomes available.