Avon

Noted (AI summary) The response outlines NICE's role in providing guidance and signposts to other organisations responsible for commissioning services, providing education and training, and funding research. The NIHR is planning a funding opportunity for a development award focussed on evaluating repurposed pharmaceutical inventions and a showcase event for post-acute infection conditions (including ME/CFS and long COVID) research later this year to stimulate further research in this field.

Noted (AI summary) NHS England expresses condolences and describes the Maternal Medicine Networks established across England; they support revision of the Royal College of Pathologists’ guidelines for urgent reporting of LFTs to incorporate different levels for pregnancy. UHBW will await national guidance from the Royal Colleges regarding a recommended reference range for urgent reporting of LFTs in pregnancy, and then set up a task and finish group to implement these across the Trust. If no national guidance is available, UHBW will look to change the reference range locally. The RCOG acknowledges the concerns raised and highlights existing online learning resources and escalation protocols, while suggesting the Royal College of Pathologists review its guidance on urgent reporting levels of LFTs for pregnant women. The Royal College of Pathologists states that its guidance on communicating critical pathology results is advice to pathologists and that individual cut-offs should be agreed locally with clinicians. The need to agree local cut offs with clinicians will be emphasised in the next revision of this document.

Noted (AI summary) NHS England acknowledges concerns about oesophageal intubation and the PUMA guidelines and states they will clarify the future direction of the Never Events Framework. They also note that all PFD reports are discussed by a working group to share learnings. The organisations agree with the coroner's concerns and highlight their existing work, including the 'no trace = wrong place' campaign, endorsement of PUMA guidelines, and emphasis on capnography in anaesthesia standards. They also express support for unrecognised oesophageal intubation to be a nationally reportable incident. The RCEM expresses support for adequate staffing, multidisciplinary simulation training, equipment standardization, intubation checklists, and capnography use, referencing an existing framework for collaboration between Emergency Medicine and Intensive Care Medicine.

Noted (AI summary) The Department of Transport refers to existing published guidance for users of e-cycles and e-scooters on battery safety, and states that pending the outcome of further research, no additional action is appropriate at this stage. The West of England Combined Authority states that specific actions to address the concerns raised by the Coroner do not lie within its strategic functions, requiring national government action in the first instance. They believe their provision of on-street rental e-scooters, e-bikes, and e-cargo bikes reduces the number of privately owned vehicles kept at home. OPSS has undertaken a program of work including commissioning research, engaging with gig economy firms to share safety information, and working with other government departments to publish guidance on e-bike and e-scooter safety. A new safety campaign with consumer messaging is expected to launch in the autumn.

Noted (AI summary) The RCN acknowledges the report and highlights its learning resources for nurses and the importance of safe staffing levels, referring to external reports and standards, but does not comment on the performance of individual nurses or actions it will take.

Noted (AI summary) The Trust added a question to the pre-procedure checklist for endoscopy to identify recent investigations and created a local learning resource on parallel pathways. They will also aim to share learning with a former clinical endoscopist and are auditing photo documentation during endoscopy. The Department of Health and Social Care acknowledges the coroner's concerns and states that the local ICB has made recommendations to the Trust. It highlights the reformed cancer waiting time standards, including the Faster Diagnosis Standard.

Noted (AI summary) NHS England acknowledges concerns about accessing Summary Care Records and allergy information but primarily describes existing requirements and procedures. They highlight national work to share learnings from PFD reports. The trust is exploring non-smartcard-based access to NCRS, with access planned for all staff in Q1 2024. They are also commissioning EPMA (Electronic Prescribing and Medicines Administration) for deployment in Q3 2024 and planning to implement 'Red Wrist Bands' for patients with allergy alerts by Q3 2024.