Berkshire

Noted (AI summary) The team reviewed the MNSI report, process, and findings and concluded that their investigation process was correctly followed. A note has been added to their investigation record to highlight the findings of the inquest. The RCOG highlights the Scientific Impact Paper (SIP) number 73, second edition, which addresses impacted fetal head at caesarean birth and sets out detailed descriptions of safe technique. The ABC (Avoiding Brain Injury in Childbirth) programme incorporates these techniques and will be rolled out to maternity units in England as part of a national programme by NHSE.

Noted (AI summary) NHS England acknowledges concerns about guidance for surgeons regarding CT scanning after abdominal surgery but notes that clinical guidelines are primarily the responsibility of NICE and Royal Colleges. They note that Clinical Quality colleagues have been asked to engage with the relevant ICB/Trust to ensure learnings have been taken. The Royal College of Surgeons of England will include an anonymised educational surgical vignette relating to the death in the Confidential Reporting System for Surgery (CORESS) surgical safety feedback reports. They will also encourage the Royal College of Surgeons of Edinburgh to do the same. The Association of Coloproctology of Great Britain and Ireland states that existing guidance on colorectal anastomotic leak management is sufficient, referring to its 2016 guidance on post-operative CRP monitoring and subsequent radiological investigation. While citing existing NICE guidance, the DHSC has shared details of the case with NICE's prioritisation team to consider if further action should be taken. The CQC has also passed details of the case to the relevant inspection team for Royal Berkshire Hospital.

Noted (AI summary) NHS England describes the NHS Pathways triage tool and its capabilities, particularly for patients unable to move. They explain the triage hierarchy, the system's functionality since 2018, and the role of local protocols. They also mention a working group that discusses reports to prevent future deaths. South Central Ambulance Service has created a directive to staff including changes to triage processes, such as ascertaining if the patient is alone, requesting contact information, using a minimum Category 3 response for patients slipping from furniture, documenting patient position, referring cases to a clinician, and ensuring cases are not closed without an appropriate response. The directive was approved and will be issued this month.

Noted (AI summary) NHS England is undertaking national efforts to educate the public on appropriate use of 999, including national public education campaigns signposting to various services and resources. They are also working to improve ambulance capacity, hospital flow, and reduce handover delays. The Department acknowledges the concerns regarding ambulance service pressures and handover delays, noting NHS England is addressing these regionally and nationally. The government is committed to safe operational waiting times, an independent investigation has reported on NHS performance, and a 10-year plan to reform the NHS is in development.

Noted (AI summary) The University of Reading has already taken several actions, including clarifying SDAT responsibilities, aligning support for MbR students with taught programmes, implementing a notification system for monitoring student engagement, and reinforcing SDAT responsibilities through new guidance. They have also clarified referral pathways for mental health support and ensured assignment with relevant professional codes of conduct. Universities UK acknowledges the coroner's concerns and states they will take the relevant lessons forward into their ongoing work, including national reviews, mental health taskforces, the University Mental Health Charter, and suicide-safer universities guidance. They note they do not have regulatory authority over member institutions.

Noted (AI summary) NHS Frimley ICB organised a cross-system meeting across the South-East region to discuss the issues raised in the report and will be writing to NHS England about this case. The response is also being shared within relevant system and regional groups. NHS Frimley ICB organised a cross-system meeting across the South-East region to discuss the issues raised in the report and will be writing to NHS England about this case. The response is also being shared within relevant system and regional groups. The General Pharmaceutical Council acknowledges the concerns and refers to existing guidance on person-centered care, reasonable adjustments for patients with cognitive impairment, and the use of MCAs. They will consider how to further raise awareness of these issues. The National Pharmacy Association will review their existing guidance and consider how to refine it, and raise awareness of the issue with Member pharmacies, and raise the matter with the sector-wide Patient Safety Group. Community Pharmacy Thames Valley expresses sympathy and notes that dispensing medication falls under a national contract, and has escalated the concerns to Frimley ICB and Community Pharmacy England and requested an anonymised case study to raise awareness. The Specialist Pharmacy Service (SPS) outlines currently available information on the management of adherence and use of medicines compliance aids and suggests changes that may help prevent future deaths, while highlighting existing resources. Community Pharmacy England will raise the concern about clearly identifying MCAs in multi-person households with the RPS and CPPSG and ask them to consider additional guidance. They will also make community pharmacy owners aware of the specific risk and actions will be taken in the autumn of this year. The MHRA believes the concerns relate to the dispensing process and are better addressed by the General Pharmaceutical Council. Slough Pharmacy has amended their processes to include removing each tray from packaging and double-checking with the patient and provides a different brand of trays with totally different packaging to any households that involve more than one person with trays.

Noted (AI summary) The Royal College of Emergency Medicine notes the coroner's concerns about delays in VTE risk assessment but states that this is the responsibility of admitting specialties, not emergency medicine doctors, once a patient has been seen by another team. NICE acknowledges that its current VTE guidance does not cover people in the emergency department prior to admission and will ask its prioritisation board to consider if guidance should be developed in this area. NHS England has contacted NICE to suggest updating their guidance on VTE assessments to recommend that they should be undertaken within 14 hours of a 'decision to admit', as opposed to admission, to account for ED wait times. Firmley Health NHS Foundation Trust will revise its VTE policy to require risk assessment within 2 hours of arrival in the Emergency Department, with a clinical review within 12 hours if the patient remains in the ED. They will also add a prompt to their electronic record system and communicate the changes Trust-wide, aiming to complete these steps within 12 weeks. The Royal College of Physicians will produce a Safety Alert for Physicians and liaise with national clinical directors and The Society for Acute Medicine regarding delays in VTE prophylaxis due to hospital admission delays.

Noted (AI summary) The Department for Transport explains the current driver licensing arrangements, emphasizing the legal requirement for drivers to report medical conditions to the DVLA and that the DVLA can only act on information received from licence holders and/or healthcare professionals about known medical conditions. They mention a Call for Evidence to gather views on the legislative framework that governs driver licensing for people with medical conditions.

Noted (AI summary) Cygnet will hold a conference to share actions on improving discharge processes, start a quality improvement project to explore a working arrangement with the Samaritans, and already has a Cygnet Social Worker on Byron Ward to coordinate discharges. Reading Borough Council outlines its Standard Operating Procedure for psychiatric hospital discharges, noting that social care practitioners are required to know and act in accordance with it. In the case of Sarah Adams, Adult Social Care were not informed of the discharge. The Trust has revised clinical risk training to increase focus on high-risk situations such as transitions of care, out-of-area placements, clear communication in discharge plans, and the 72-hour follow-up process. They have also strengthened guidance to teams on the 72-hour follow up process.