1. ITV Report

Terms of reference of HSSD inquiry

The States of Alderney's Policy and Finance Committee and the States of Guernsey's Policy Council has set these terms of reference for the inquiry investigating HSSD's referral of Dr Rory Lyons to the police and General Medical Council.

1: Identify and describe a detailed chronology of events from the time that concerns were first raised about Dr Lyons’ practice to his suspension and to the initiation of the police investigation. This will include:

  • The complaints made
  • Who made the complaints and with whom were they raised and then escalated, including the Board, senior and executive management of HSSD
  • HSSD’s investigation of these concerns, internally and externally, including the use of specialist advice, within the established processes
  • The actions taken by HSSD to safeguard patients and prevent harm, including the timeliness of such actions and the measures taken
  • The extent to which the above was properly recorded and communicated, both internally and externally (as appropriate at the time)

2: To provide an independent assessment of the processes used to investigate concerns that were raised and the action taken to address those concerns, identifying both good practice and any areas for improvement

3: To specifically review the HSSD’s actions and governance procedures in response to, and any subsequent actions taken following receipt of pertinent reports/complaints

4: To evaluate the effectiveness of the HSSD’s systems for ensuring the safety of patients, for clinical governance and for responding to staff raising concerns, throughout this period, specifically and only in relation to Dr Lyons’ practice

5: To identify and evaluate the steps taken by the HSSD to ensure that relevant external agencies/bodes were alerted to the concerns raised concerning investigations related to Dr Lyons, as appropriate

6: In respect of all above aspects of the scope of the review, to:

  • Deliver a set of findings based on evidence obtained during the review
  • Make recommendations for any improvements and/or actions required in HSSD’s arrangements or other lessons to be learned arising from management of the clinical concerns raised regarding Dr.Lyons

The inquiry will be carried out by two people from the Good Governance Institute. They are:

  • Mark Butler (who will lead the team.) He is a former NHS Chief Executive and a highly experienced investigator, including having recently led a major whistle blowing investigation for GGI and the Trust Development Authority in Southport and Ormskirk Hospitals that recently concluded. Mark is highly regarded in the field of executive governance and decision-making and supports this with further executive experience in education and social care.
  • Peter Molyneux is an experienced NHS Chair, and has worked with GGI over a number of years on governance reviews. Peter has served on Boards in the public, private and voluntary sectors and has extensive experience in decision-making and executive engagement. Peter has managed projects covering reputation management, governance, integration and partnerships for the Department of Health, the Homes and Communities Agency, the Joseph Rowntree Foundation,the Shaw Trust and the National Housing Federation.

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