A frailty MDT with no terms of reference and no owner for actions
Northgate Community Frailty Service runs a weekly 45-minute multidisciplinary team meeting in a room booked for 30 minutes. Twenty-two patients are listed. The consultant chair is on leave for six weeks; the specialist registrar chairs 'because she is the most senior clinician present'. A physiotherapist and a social worker join by phone from another site and are frequently unable to hear the plan. Decisions are typed into the electronic record as free text under the heading 'MDT outcome', sometimes the same day, sometimes the following week. Last month a patient was admitted after a falls plan agreed at the meeting was never actioned; nobody can establish who accepted the action. The service manager asks you to review how the meeting is governed before the next inspection.
1. Rank the governance failures in this meeting by the patient risk they create, and justify the ranking.
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Rank by likelihood x severity, and by whether the failure is detectable before harm.
- No named owner or tracking of actions (highest). This has already produced harm. A multidisciplinary decision is only a decision when someone owns it and there is a visible due date. Untracked actions fail silently, so nothing prompts rescue.
- Twenty-two patients in 30 booked minutes. The agenda cannot be delivered, so cases are curtailed in a way nobody records. Omissions become invisible and the meeting believes it has reviewed everyone.
- Chair by seniority rather than appointment. The registrar has clinical standing but no delegated authority to enforce the agenda, defer cases or hold colleagues to a standard, and cannot escalate.
- Remote attendees without parity. A plan agreed without the physiotherapy or social work view is a partial plan, and dissent is not captured in free text.
- Free-text outcome recorded up to a week later. Not contemporaneous, not auditable, and not a reliable source if the patient deteriorates.
The first is both the most dangerous and the cheapest to fix, which is where a review should start.
2. Set out the components you would put into written terms of reference, and propose a quorum rule that would prevent these problems.
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Content of terms of reference
- Purpose and scope: which patient population is in and out of scope.
- Membership: named roles, a named deputy for each, and which disciplines must be represented.
- Chair: appointed, with a defined tenure, competence expectations and a deputy.
- Standing agenda and time allocation per case, with a rule that cases not reached are carried forward and logged.
- Referral and triage rules, including a mandatory data set before a case can be listed.
- Documentation standard: where the record is written, what fields are mandatory, and a same-day deadline.
- Action log with named owner and due date, reviewed at the start of every meeting.
- Confidentiality, conflict of interest, escalation route, and annual review.
Quorum rule. Do not use a headcount. Define quorum by discipline: the chair plus at least one clinician from medicine, nursing, therapy and social care, with remote attendance counting equally. Add the rule that no decision on a patient may be taken without the discipline holding the key information; that case is deferred and logged rather than voted through by whoever is in the room.
3. How should the unactioned falls plan be handled now, as an incident and as a governance task?
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Immediate clinical response. Establish the patient's current condition and whether harm is ongoing; ensure the falls plan is now in place and the patient and family know what has changed.
Reconstruct, do not assume. Pull the record, the meeting notes and the messages; identify what was agreed, what was written, who was present and what each person understood their role to be. The purpose is to find where the system lost the action, not to select a culprit.
Duty of candour. Hold an open explanation with the patient, apologise for the failure, explain what will change, and record the conversation.
Report and learn. Log as a patient safety incident, ask the governance group to review it, and feed the finding into the redesign: owner field, due date, standing review of the log, and an audit of action closure at 30 and 90 days.
Do not simply remind staff to be more careful; the failure was structural, so a reminder changes nothing measurable.