Avon

Action Planned (AI summary) Torbay and South Devon NHS Trust has discussed the case with relevant clinical teams and is implementing actions including: Paediatric clinicians learning about the Regional Genetic Service, Head of Regional Clinical Genetics Service attending a meeting with Paediatric clinical teams, twice yearly educational contact at clinical educational meetings, establishment of a regular advice point during/after the monthly clinics undertaken by the Regional Clinical Genetics Service in TSDFT. Bristol NHS Foundation Trust is working with Torbay and South Devon NHS Foundation Trust to finalise the Principles of Shared Care for Endocrine and has developed a patient information leaflet. It has been agreed that Service Levels Agreements will formalise the agreements in place with clear lines of accountability and responsibility.

Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.

Action Planned (AI summary) The Department of Health and Social Care plans to publish a White Paper in early 2020 responding to the Independent Review of the Mental Health Act and will consult publicly on proposals to amend the Act.

Action Planned (AI summary) The University has shared its mental health and wellbeing strategies with sector colleagues and provided support to other institutions where student deaths have occurred. From September 2019 the SPRG will oversee the undertaking of a serious incident review for every suicide or serious attempted suicide. UCAS is redesigning the question about disabilities, special needs, or mental health issues on the application form, with a roundtable discussion planned for July and implementation in 2020 for the 2021 entry. The UCAS Hub is also being explored to alleviate anxiety and signpost support services. The department will work with Universities UK to remind HE providers of the recommendation to carry out serious incident reviews. Public Health England is happy to work alongside partners to support the development of a serious incident framework.

Action Planned (AI summary) Persimmon Homes attended meetings with North Somerset District Council and agreed to attend a further meeting with Network Rail to explore an acceptable resolution, including a significant financial contribution for construction of the footbridge. North Somerset Council will meet with Persimmon Homes, seek Network Rail's engagement, and consider measures to improve crossing safety. By specific dates, they will seek Network Rail's confirmation of design requirements, agree to a draft project plan, and use best endeavors to determine any planning application.

Action Planned (AI summary) NHS Digital acknowledges that the question about a recent surgical procedure or operation is not specifically asked in a sub-section of their abdominal pain pathways and are reviewing how this might be included as part of a larger clinical review, which is due for completion later this year; and they do currently require that all users of NHS Pathways seek to talk directly with the patient where possible.

Action Planned (AI summary) The Trust plans to extend the height of the parapet anti-climb fencing over the span and build a walkway beneath each of the buttresses, requiring planning permission and compliance with legislation.

Action Planned (AI summary) A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and issue a vignette of Charlotte's care as a reflective training exercise, emphasizing multi-disciplinary working and care planning.

Action Planned (AI summary) CQC carried out a comprehensive inspection of Avon and Wiltshire Partnership NHS Trust (AWP) in June 2014, leading to enforcement action and four warning notices. AWP addressed the warnings, including physical improvements to Hillview Lodge. A further comprehensive inspection will be undertaken before April 2016. The trust does not endorse harm minimisation strategies, but after a staff member mooted 'safe self-harm' they plan to issue an internal safety alert to all clinical staff to remind them of this position.

Action Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.