Bedfordshire and Luton

Action Taken (AI summary) Further training on risk assessment and suicide prevention is being delivered to staff in Bedfordshire crisis services. A new Clinical Director for Crisis Pathway and Liaison has been appointed to review the crisis pathway, and the Trust is working with external experts to develop a new risk assessment tool for wider rollout; suicide prevention training is also being reviewed and refreshed.

Action Taken (AI summary) Network Rail has trained over 20,000 railway staff to intervene with people who may be at risk of suicide, funded and implemented a team of eight patrollers in the Thameslink area to conduct suicide prevention patrols, and engaged with the local authority to discuss community-based suicide prevention measures. They also highlight existing fencing and risk assessment protocols.

Action Taken (AI summary) M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months. B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months.

Action Taken (AI summary) FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither would add a further method of entry for emergency services.

Action Taken (AI summary) The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires in white goods on 19 July. They have also supported the development of a new BSI code of practice on corrective action and recalls and commissioned research to understand how to increase the impact and effectiveness of product safety messages.

Action Taken (AI summary) East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact information and guidance for responding to messages.

Action Taken (AI summary) The Trust has updated its Operational Policy for CMHT, now requiring opt-in letters to be sent within 5 working days, subject to local audit. This followed a serious incident review that identified delays in sending such letters.

Action Taken (AI summary) Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at all times.

Action Taken (AI summary) The hospital revised its VBAC form to incorporate a full clinical assessment including abdominal palpation and a vaginal examination for women undergoing IOL with a history of previous caesarean. Actions relating to improving the timeliness of epidurals and decision making around non-elective caesarean sections have been completed and implemented.

Action Taken (AI summary) The Standard Operating Policy for obstetric ultrasound scanning has been amended to include consultant requests for detailed delivery plans from tertiary centers, documented in patient notes. This policy has been added to the Trust guidelines, obstetric doctors have been notified, and referrals to tertiary centers will be monitored by the weekly Multidisciplinary Paediatric Plans of Care Meeting.

Action Taken (AI summary) The Trust developed and implemented a position statement/action plan to ensure a robust system for urgent tests and imaging, including publicizing service details on the trust intranet and extending pharmacy opening hours. Electronic reporting of images is in place, and online electronic requesting of radiological examinations is being introduced with training.

Action Taken (AI summary) The trust has made changes to its Serious Incident reporting process, ensuring clinical information is made available, decisions are taken by Executive Directors, and the process no longer requires confirmation of the Cause of Death before reporting. Weekly and monthly meetings are held to monitor investigations and reported deaths.