A NSW Government website


Review of Performance and Future Safety & Quality Priorities

NSW Health has identified five State Outcomes that cover the range of functions and services provided across healthcare settings. The Outcomes are described in detail in the NSW Health Outcome and Business Plan 2022-23.

This section reports HNELHD’s performance for the 2021-22 financial year on a range of performance measures that align with the State Outcomes. Related initiatives and actions are also presented, highlighting the efforts the the District is making to continually improve our services.

NSW Health Outcome 1: Keeping people healthy through prevention and health promotion

This outcome reflects that preventive and population health measures are critical to keeping people healthier. It covers a range of functions including to promote public health, control infectious diseases, reduce preventive diseases and death, help people manage their own health including mental health, and promote equitable health outcomes in the community.

53% of children seen by the health service had their height and weight recorded in their electronic medical record.

With more than one in five children in NSW being obese or overweight, the NSW Ministry of Health have made reducing obesity a priority. Programs and resources are available to help with prevention and intervention for childhood obesity. A variety of resources and guidelines are available to support measuring height and weight for all children. The resources provide a guide to:

  • Measuring height and weight
  • Having conversations with parents of children who are above healthy weight
  • Making referrals to programs aimed at helping children who are above a healthy weight such as Go4Fun
These measurements are collected regularly as part of outpatient and admitted services. HNELHD is working to ensure that these measurements are being identified in the electronic systems that record compliance with the policy.
1,990 pregnant women accepted referrals to the Get Healthy in Pregnancy coaching service
43 Aboriginal children underwent surgical procedures to treat chronic otitis media.
43.4% of Aboriginal and 13.4% of non-Aboriginal pregnant women smoked at some point during their pregnancy.

19.7% of pregnant women who smoke quit smoking during the second half of pregnancy.

The Maternal Health Initiative, a collaboration between HNELHD Population Health and Maternity Services was highlighted in the 2020-21 Safety and Quality Account.

The Maternal Health Initiative has been successful in increasing the number of pregnant women who accept support to quit smoking. The initiative has focussed on increasing the skills of midwives, Aboriginal Health Workers and doctors to support pregnant women to quit smoking and encouraging them to accept help such as free nicotine replacement therapy and referrals to support services such as the NSW Quitline.

63.6% of families with a new baby received a 1-4 week health check by a Child and Family Health Nurse.

Health checks provide families with access to essential services and early intervention where required, optimising the child’s developmental outcomes. The 1-4 week health check is the first of a schedule of these checks offered by NSW Health services as part of the First 2000 Days Framework.

During 2021-22, HNELHD Child and Family Health Nurses conducted over 5,700 1-4 week checks across 49 different clinic locations. The services work to engage families and provide a seamless transition from maternity to child and family health services.

95.5% of children in HNELHD are fully immunised at one year of age.

BreastScreen participation rates:

  • 55.5% of women aged 50-69 years
  • 61.5% of women aged 70-74 years
173 patients commenced direct-acting antiviral treatment for Hepatitis C

Hepatitis C is a liver infection that has serious health outcomes, inlcuding liver cancer, if left untreated. Available research suggests that the rate of hepatitis C in people admitted to mental health units is up to fifteen times higher than the general population, and that the rate of testing and treatment is lower.

With funding assistance from NSW Ministry of Health, HNELHD are running a pilot project aimed at improving access to hepatits C testing and treatment for people admitted to mental health units. The project supports patients to access testing and commence treatment during their admission, and puts supports in place to aid the completion of treatment after discharge. The project has developed training resources for staff, education materials for patients, trialled new testing and treatment methods and is collecting clinical data and patient/staff feedback to measure the success of the project.

3,506 Drug and Alcohol liaison consultations provided to other treating teams during patients’ admissions.

HNE Drug and Alcohol Clinical Services (DACS) provide specialised treatment services for people with substance use problems. The DACS Hospital Drug and Alcohol Consultation Liaison service works collaboratively with admitting medical teams, providing support and treatment advice on the management of patients’ drug and alcohol related issues.

DACS recently implemented the Take Home Naloxone program across the District to reduce opioid overdoses in the community. The Hospital Drug and Alcohol Consultation Liaison team provided education and Naloxone to 165 inpatients in the 2021-2022 financial year.

NSW Health Outcome 2: People can access care in out of hospital settings to manage their health and wellbeing

Healthcare extends beyond the hospital and connects across settings to reduce the burden of chronic disease, assist people with conditions to live well and avoid complications, support people to recover from illness and injury, and prevent avoidable hospitalisations. NSW Health services include non-admitted and community-based services, subacute services, hospital in the home, and dental services

80% of families enrolled in the Sustaining NSW Families Programs are continuing in the program.

69% of enrolled families completed the program by the time the child reached 2 years of age.

27.5% of hospital services (admitted care and emergency presentations) were associated with potentially preventable conditions.
Domestic and family violence routine screening was conducted and documented for 40.2% of women attending Child and Family Health services, Drug & Alcohol, and Mental Health services.

Domestic and family violence (DFV) involves enormous personal harm, impairs children's health and development, and incurs substantial social and economic cost to society. As emergency departments (EDs) are often the first point of contact with the health system for victims of DFV, it is important that victims are identified and supported whenever they present to any ED across the District.

HNELHD Violence Abuse and Neglect Services are designing an ED model of care that will be available 24/7 for victims of DFV. The model will be trialled at Tamworth ED and will include identification and support for victims of DFV in the ED, timely psychosocial crisis response, and referral for follow up. The implementation is currently at the stage of engaging with stakeholders and providing training to the workforce, and the trial will be evaluated in April 2023.

2.2% of non-admitted services were provided through telehealth.

There has been continued growth in the use of telehealth by many services in across District. myVirtualCare, the state-wide telehealth system supported by eHealth, has become part of regular activities for many HNELHD services. Examples of services that have started using or expanded their use of myVirtualCare include:

  • COVID Care in the Home
  • Interpreter services
  • Virtual Kids, reducing the time children and their families wait in the Emergency Department at John Hunter Children’s Hospital.
  • Emergency Mental Health reviews to 26 emergency departments across the District
  • Group education sessions including psychotherapy, pain management, parenting education classes and cardiopulmonary rehabilitation.

84.4% of the discharge summaries completed for inpatient stays were received electronically by General Practitioners

13.1% of patients discharged from acute mental health services are readmitted within 28 days of discharge.

Across the District there was a full-time equivalent of 8.7 Mental Health Peer workers employed as at June 2022.

After discharge from mental health facilities, 73.2% of patients received follow-up community care within 7 days.

Readmission following discharge from a mental health unit can occur for many different reasons. The HNELHD Mental Health Service is aiming to reduce readmission rates for Aboriginal people through a number of approaches, one of which is the employment of the Aboriginal Mental Health and Social and Emotional Wellbeing Care Navigator.

The Care Navigator supports clinical teams in the development of culturally informed assessment, treatment approaches, and discharge planning. They work to ensure that social, cultural and historical contexts are at the forefront of services offered through mental health services. The Care Navigator works to establish systems, services and processes between mental health and other services. These linkages promote collaboration between services, reduce duplication and ensure appropriate support at transitional points in care for Aboriginal people.

Working alongside the Care Navigator is the Peer Worker. The Aboriginal Mental Health and Social and Emotional Wellbeing Peer Worker delivers immediate support and compassionate care with the insight and understanding of a person who has lived experience of a mental illness. The Peer Worker is also a source of information about other community-based services such as housing support, relationship counselling and financial assistance.

NSW Health Outcome 3: People receive timely emergency care

The emergency department is often the first point of contact for people needing urgent healthcare. The measures below reflect the capacity of health services to transfer patients from ambulances to the emergency department, to see emergency patients, and to move patients who need admission to wards in a timely manner.

28% of patients presenting to emergency department (ED) who require admission had a total time in ED of less than 4 hours.

The percentage of people who presented to ED who were treated within the clinically recommended timeframe was:

  • 100% Triage 1 (seen within 2 minutes)
  • 81% Triage 2 (seen within 10 minutes)
  • 71.5% Triage 3 (seen within 30 minutes)

84% of patients were transferred from ambulance to ED within 30 minutes

HNELHD is trialling novel interventions in order to support emergency departments to provide timely care.

Collaborative Care of Vulnerable People aims to reduce repeated preventable emergency department presentations. Patients who have a history of frequent presentations identified and their care needs are reviewed by a multidisciplinary team. The team works collaboratively with patients and their GPs to coordinate and access appropriate healthcare and support services in the community. The trial resulted in a 46% decrease in the rate of emergency department presentations of the trial group, which consisted of 116 patients.

Virtual Kids is a virtual acute review service for children aged 0-17 with acute respiratory illness. Children who present to emergency that are well enough to be cared for in the community are offered daily follow-up consults via telehealth and monitoring using the CareMonitor App. Virtual Kids has provided services to over 780 children in the initial 3-month trial period. Feedback and clinical outcomes have been overwhelmingly positive. Evaluation of the service is underway, including the possibility of expanding the service to cater for other conditions commonly seen in ED including asthma, gastroenteritis and diabetes.

There were 64 instances where patients with mental health presentations stayed in emergency departments longer than 24 hours.

HNELHD is collaborating with NSW Ambulance and NSW Police on the Mental Health First Responder service. This initiative provides Police and Ambulance officers with priority access to specialised mental health triage services via telehealth for people experiencing mental health concerns. The triage is a brief mental health intervention which helps to identify the most appropriate type of care for the person. The mental health clinician and the Police or Ambulance on scene work together following triage to connect the person with the right level of care to meet their needs, which may involve:

  • follow-up by community mental health
  • community-based supports such as GP or other relevant services
  • transportation to hospital for mental health assessment

NSW Health Outcome 4: People receive high-quality, safe care in our hospitals

This outcome reflects the state’s responsibility to manage and administer public hospitals. When people are admitted to a hospital in New South Wales, they can expect world-class medical and surgical care within clinically recommended timeframes, with NSW Health operating the largest public hospital system in Australia.

Between July 2021 and June 2022, the percentage of patients who had their surgery within the recommended timeframe was:

  • Category 1 - 100%
  • Category 2 - 94%
  • Category 3 - 94%

The number of patients waiting for elective surgery beyond the recommended timeframe as at June 2022 was:

  • Category 1 - 0
  • Category 2 - 207
  • Category 3 - 363

1,455 children were admitted from the elective surgery waiting list (430 fewer than the 2021-22 target). There is no waiting time for children requiring surgery in HNELHD, as there is sufficient capacity to meet demand.

The Omicron wave of COVID-19 resulted in the suspension of all non-urgent surgery across NSW during January, and has maintained substantial pressure on the health system since that time. This has resulted in patients across NSW waiting longer than the clinically recommended time for their surgery.

Surgical services across HNELHD have been addressing the backlog of patients by coordinating services with private healthcare partners, in line with NSW Health’s pandemic response plan.

Despite dealing with unprecedented clinical load, HNELHD continues to pursue improvements in safety and quality of care. An example of this is the recent purchase of a certified medical 3D printer to be based at the Hunter Innovation Living Lab (HILL), which is currently under development at the John Hunter campus.

3D printing is being used in an increasing number of clinical areas, and the ability to produce items locally will enable clinicians and engineers to collaborate directly and reduce turnaround times. The 3D printer will be able to produce anatomical models to support patient diagnosis and assist surgeons to plan for complicated surgery. 3D printed models will also be used to enhance simulation training for clinicians.

Hospital-acquired complications

Hospital-acquired complications cover a wide range of conditions that can occur during a patient’s admission, and that may have been preventable. The rate of hospital-acquired complications is monitored in all NSW hospitals as a measure of the safety and quality of care.

Between 1 July 2021 and 30 June 2022, 97.8% of hospital admissions across HNELHD were free of hospital-acquired complications . The table below shows the rate of hospital-acquired complications per 10,000 “episodes of care,” and some of the strategies in place to further reduce their occurrence.

  • hospital acquired pressure injuries - 6.5 per 10,000 episodes of care
  • fall-related injuries-resulting in fracture or head injury - 5.3 per 10,000 episodes of care
  • healthcare associated infections - 104 per 10,000 episodes of care
  • hospital acquired respiratory complications - 31 per 10,000 episodes of care
  • hospital acquired blood clots - 7.6 per 10,000 episodes of care
  • hospital acquired renal failure - 1.2 per 10,000 episodes of care
  • hospital acquired gastrointestinal bleeding - 10 per 10,000 episodes of care
  • hospital acquired medication complications - 7.8 per 10,000 episodes of care
  • hospital acquired delirium - 35 per 10,000 episodes of care
  • hospital acquired incontinence - 2.2 per 10,000 episodes of care
  • hospital acquired endocrine complications - 25 per 10,000 episodes of care
  • hospital acquired cardiac complications - 35 per 10,000 episodes of care
  • hospital acquired 3rd or 4th degree perineal lacerations - 371 per 10,000 episodes of care
  • hospital acquired neonatal birth trauma - 54 per 10,000 episodes of care

Rates of HACs vary over time and between hospitals. This can be due to seasonal influences such as the winter flu season, caseload differences where a hospital specialises in a particular type of care, or it could be due to differences in the care provided.

HNELHD has 25 hospitals, and no two hospitals are the same. It is important to be able to differentiate warranted variation from unwarranted variation in patient care. HNELHD is committed to minimising unwarranted clinical variation and identified the development and implementation of the Clinical Variation Framework as a priority in last year’s Safety and Quality Account.

The Clinical Variation Framework was released December 2021, accompanied by a suite of tools and resources to assist clinical teams identify and assess instances of unwarranted clinical variation. The resources that have been developed align with published standards such as Clinical Care Standards, Leading Better Value Care, and Hospital Acquired Complications definitions.

Where an HNELHD hospital has a HAC rate that varies from the predicted rate, the Framework provides guidance and tools to assess whether the variation is warranted or unwarranted. Where unwarranted variation is identified, actions to reduce the risk of HACs occurring are initiated and updates on progress are provided to the relevant Clinical Quality and Patient Care Committee.

The rate of admitted Aboriginal patients who discharged against medical advice was 0.8%

The rate of unplanned hospital readmission within 28 days of discharge was:

  • 4.7% for Aboriginal patients
  • 4.8% for all patients
Patient Survey Results

Patient experience index - patients’ ratings of staff teamwork, organisation of care, and overall rating of care.

  • Adult admitted patients – 8.5/10
  • Emergency department patients – 8.4/10

Patient engagement index - a measure of information provision and involvement in decisions about care.

  • Adult admitted patients – 8.5/10
  • Emergency department patients – 7.6/10

Emergency departments across HNELHD are implementing the strategies of NSW Health’s Emergency Department Patient Experience initiative. The initiative aims to create an environment that makes patients, carers and their families feel welcomed, safe, cared-for and empowered.

In addition to waiting room enhancements such as mobile phone charging stations, Patient Experience Officers are employed in nine of the District’s emergency departments during peak demand times. Patient Experience Officers help make sure that people presenting to emergency are oriented to the amenities of the department, and act as a link between consumers and the clinical operations of the department. They also help collect patient feedback via an online survey.

Patient survey feedback is taken into consideration when planning changes to waiting rooms and other parts of the departments. The emergency department is a fast paced and often stressful workplace. With over 80 percent of survey responses being positive, the patient survey is a welcome source reinforcement and encouragement for the emergency department staff.

70% of mental health consumers rated their care in HNELHD as very good to excellent.

The COVID-19 pandemic response required that visits by friends, families and carers to consumers in mental health units were ceased at times during 2021-22. Social interaction plays an important part in the mental health recovery journey, and these restrictions negatively impacted upon many of our consumers.

As the levels of COVID-19 transmission in the community have decreased, visitation and leave breaks have been reinstated, and the full program of therapeutic groups in inpatient units are again on offer.

Seclusion occurred in 4.4% of admitted acute mental health stays.

There were 8.8 episodes of seclusion per 1,000 bed-days in acute mental health units.

The average duration of each acute seclusion episode was 3.4 hours.

HNELHD continues to progress implementation of Safewards across all inpatient mental health facilities. The objective of the Safewards model is to reduce conflict and the use of containment within mental health services, improving the safety of patients, staff and visitors.

Implementation of Safewards strategies involves significant planning, staff training and consumer engagement. Units within HNELHD Mater Mental Health Centre have commenced implementation of the Safewards strategies. Tamworth Mental Health Unit has completed a needs analysis, implementation plan and timeline. Units at Morisset, Maitland and Nexus (John Hunter) plan to commence implementation in early 2023.

For every 1,000 bed-days in mental health inpatient units, 1.45 involuntary patients abscond.

Modern, purpose built facilities support the provision of best practise mental health services. A number of mental units within the district are undergoing redevelopment and improvements.

The Maitland Mental Health Unit moved to brand new premises in January 2022, and the Nexus child and adolescent unit has undergone infrastructure changes to ensure the safety of the young people admitted to the unit.

NSW Health Outcome 5: Our people and systems are continuously improving to deliver the best health outcomes and experiences

A skilled workforce with access to world-leading education and training, and a system that harnesses research and digital innovation is essential to continuously improve outcomes and experiences of care across the system.

NSW Public Service Commission People Matter Employee Survey (PMES)

39% of staff believe the culture at their workplace has improved over the past 12 months (3.0% less than 2019).

31% of staff were confident that the organisation will act on the results of the People Matter Survey (3.0% less than 2019).

7% of Aboriginal staff and staff who speak a language other than English at home reported experiencing racism at work.

PMES results specific to individual services are presented by local management teams to their individual services at each level of the organisation. Survey action groups are formed within each service that include a representation from all the smaller teams and disciplines that sit within the service. The action groups lead the development of local action plans to address PMES feedback. Action plans are shared with staff and updates are incorporated into accountability tools of the Excellence framework to close the loop to staff regarding actions taken as a result of PMES results.

HNELHD strives to deliver Excellence to every patient, every time. Excellence is delivering the best possible care to each patient, in a safe, healthy and culturally sensitive environment. The principles of Excellence are implemented in HNELHD via many practises and tools including Leader Rounding with staff, Standards of Behaviour, and accountability processes such as Monthly Accountability Meetings and 90 Day Action Plans.

Staff Engagement in the People Matter Survey was 1% less than the previous survey.

60.8% of staff have had a performance development review within the last 12 months.

Staff performance reviews are collaborative and structured discussions, allowing employees and their managers to recognise achievements, provide feedback regarding performance, and explore other developmental opportunities within the organisation for the employee.

This year HNELHD Tablelands Sector (encompassing areas including Armidale, Glenn Innes, Inverell, and Tenterfield) achieved a 30% increase in the completion of performance reviews. The Sector employed multiple strategies, such as tabling performance review performance at management meetings, regular reporting, and automated alerts when reviews were coming due for staff.

Across the District there was a full-time equivalent of 6.4 Aboriginal Health Practitioners employed as at June 2022.
HNE LHD is committed to supporting the Aboriginal Health Worker and Aboriginal Health Practitioner workforce. A recent example of this commitment is the Aboriginal Cultural Supervision Yarning guideline. The guideline sets out a supervision structure that is designed to support the professional and cultural development and satisfaction of Aboriginal staff, with the focus on improved care and outcomes for Aboriginal communities.

5.5% of HNELHD’s total workforce identify as Aboriginal.

It takes an average of 9 business days to approve, decline, or defer recruitment once a request is made.

The District achieved a 7.9% reduction in compensable workplace injury claims (the target is a 10% reduction).

HNELHD continues to improve workplace safety and embed safety culture across the District. Strategies include the We’re Safe Calendar, which establishes a District wide safety focus each month, providing discussion prompts and activities for use at team meetings.

Priority areas for the Work Health and Safety team continue to be the three main occupational hazards in healthcare:
  • Manual handling
  • Violence and aggression
  • Slips, trips and falls

HNELHD is committed to developing a culture where all staff feel empowered to raise occupational health and safety issues in their workplace.

100% of human research ethics applications (involving more than low risk to participants) approved within 90 calendar days.

97% of site-specific research governance applications were authorised within 60 calendar days.

HNELHD Safety and Quality Priorities

Closing the Loop on Last Year's Priorities

Five priority initiatives were identified in last year's HNELHD Safety and Quality Account. The following section lists each priority and provides a brief update:

Management of Rural Coronary Syndromes (MORACS)

In the time since the last HNELHD Safety and Quality Account, the Management of Rural Coronary Syndromes project was re-named TeleECG - Centralised acute coronary syndrome decision support service. The success of the TeleECG service is highlighted in this year’s Account in the Improvements Achieved through Priority Initiatives section.

Implement initial recommendations from the Henry Review

This year’s Safety and Quality Account highlighted the ADHD Shared Care initiative, which is directly addressing recommendation 56 from the Henry Review in paediatric services in NSW: “Pilot studies across NSW implement ways for general practitioners to write repeat prescriptions for stimulant medication for ADHD”. The ADHD model of care is an ongoing priority for HNELHD and is being expanded to include rural and regional parts of the District.

Embed the new HNE Strategic Framework to improve Aboriginal Health and Wellbeing across the organisation

The HNELHD Strategic Framework to Improve Aboriginal Health and Wellbeing was developed in 2021. The Framework shifts HNE’s Closing the Gap focus to one that embraces Aboriginal cultural and social domains and their fundamental connection to health. The Framework includes five Strategic Principles which can be applied to all parts of the health system to apply an Aboriginal cultural lens to how we engage, design and deliver our services to meet the needs of Aboriginal consumers and staff, and has been embedded in the HNELHD Strategic and Operational Plans.

Towards Zero Suicides in Care

HNELHD continues to make substantial progress on the state-wide Towards Zero Suicides initiatives. Safe Haven Hubs are now operational in both Newcastle and Tamworth. A major focus during 2021-22 has been delivering training in the Suicide Prevention Care Pathway. The pathway’s development draws on international research and has been tailored to local needs through a co-design process with carers, consumers and frontline staff. A number of Yarning Circles were conducted across the District for consultation with Aboriginal Communities. The training has been delivered to multiple HNE Mental Health services across the District and is ongoing.

Clinical Variation and Leading Better Value Care

The HNELHD Clinical Variation Framework was released December 2021 and has been integrated into the District’s Clinical Quality and Patient Care Framework. An intranet site containing a suite of tools and resources to assist clinical teams identify and assess instances of unwarranted clinical variation has been published, and is being promoted via an education and awareness campaign. The resources that have been developed align with published standards such as Clinical Care Standards, Leading Better Value Care, and Hospital Acquired Complications definitions.

Safety and Quality Priorities for 2022-23

The following list highlights some of the safety and quality priorities that are being implemented over the coming year. These and other actions are described in the 2021/22 Hunter New England Local Health District Operational Plan and/or the Strategic Plan 2021 to 2026.

24/7 Domestic and Family Violence (DFV) response service

Emergency departments are often the first point of contact with the health system for victims of DFV. HNELHD are committed to ensuring that victims of DFV are identified and supported whenever they present to any emergency department across the District. HNELHD are designing a DFV response service that will be available 24/7, and trialling this model at Tamworth Hospital Emergency Department over the coming year.

Aboriginal Cultural Supervision Yarning Program

The Aboriginal Cultural Supervision Yarning Program is designed to support the professional and cultural development of Aboriginal staff in HNELHD. Aboriginal Cultural Supervision Yarning is a collaborative and professional framework that is intended for the Aboriginal workforce to negotiate cultural ways with safety and trust whilst walking and working in two worlds. The Program is planned with a focus to improve retention, cultural safety and well-being of Aboriginal staff, and improve engagement and outcomes for Aboriginal consumers and communities.

HNEkids Compass project

Children with complex medical needs and their families face many disruptions and challenges in navigating the healthcare system. The HNEkids Compass project aims to better connect and coordinate care for children with chronic and complex health needs. The project team are working with children, their families and health staff to co-design a model of care that will be implemented across the District.

Expansion of services to support consumers in the final two years of life

HNELHD is implementing a range of initiatives to improve end of life care across the District in alignment with the NSW Health End of Life and Palliative Care Framework. These improvements aim to ensure care is person-centred by recognising and supporting families and carers, by ensuring care providers are accessible and competent in end of life and palliative care, by ensuring care is well co-ordinated and integrated, and that people have equitable access to care across the District.

Mental Health First Responder service

The Mental Health First Responder service provides Police and Ambulance with priority access via telehealth to specialised mental health triage services for eligible people. HNELHD will be introducing this service in rural and regional areas across the LHD in the coming 12 months to enable more consumers who are experiencing mental health concerns to access the most appropriate type of care, in the most appropriate setting.

Attestation Statement

Download link for the attestation statement Health services in Australia are regularly accredited against the The National Safety and Quality Health Service (NSQHS) Standards by an accrediting agency. The accrediting agency for Hunter New England Health is The Australian Council on Healthcare Standards.

All Australian health service organisations are required to submit an annual attestation statement to their accrediting agency. The attestation statement is a formal document stating that the District is complying with safety and quality and clinical governance processes as set out within the NSQHS Standards.

The Attestation Statement can be downloaded by clicking on the image to the right: