Birmingham and Solihull

Action Planned (AI summary) NHS England has established a serious incident group to address issues at the GP practice, including systems for monitoring letters and vaccine availability. They are developing a letter to GPs reinforcing responsibilities, and a Performance Advisory Group will consider regulatory action for the GP.

Action Planned (AI summary) Birmingham City Council will develop and consult on road safety improvements along Grove Lane, with implementation planned for 2017/18 and aspiration for completion by July 2017.

Action Planned (AI summary) Following meetings between the hospitals involved, actions have been agreed to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action table is attached. Following meetings between the hospitals involved, a detailed action plan has been developed and commenced to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action plan is attached.

Action Planned (AI summary) The Resuscitation Council UK promotes CPR and AED use through education, research, and collaboration, including overseeing the distribution of £1,000,000 for public access defibrillators and redesigning PAD signage. The Department for Education published guidance on automated external defibrillators in April 2016 and has since published new guidance relevant to further education colleges. They will also write to the Association of Colleges to highlight this guidance. NHS England acknowledges concerns about out-of-hospital cardiac arrest survival. The Treasury has allocated £2m for public access defibrillators, and the Department for Education has issued guidance encouraging CPR training and PADs in schools. The BHF provides training resources for CPR and PAD familiarisation, funds PADs, and offers a Genetic Information Service for inherited heart conditions, which they have promoted to coroners.

Action Planned (AI summary) Following a SUDIC case discussion, the practice incorporated continuous oxygen saturation readings during nebulisation into their acute asthma management protocol and implemented outcomes from a serious case review into their emergency protocol. NHS England acknowledges the concern regarding suction equipment and oxygen at the GP surgery, and highlights ongoing work to improve asthma management in primary care by communicating updated guidelines to GP practices and CCGs. They have also requested that the CQC ensure primary care services carry the necessary equipment and skills to address respiratory emergencies. The CCG reviewed guidance on basic equipment requirements for GP practices, including CPR training and equipment such as AEDs and oxygen, and will ensure practices adhere to this guidance via contract visits and disseminate learning from this incident to other CCGs.

Action Planned (AI summary) The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust will also implement a more robust approach to Environmental and ligature risk assessments and extend the simulation of medical emergencies on wards.

Action Planned (AI summary) Following a significant event review, the practice agreed to share the event with clinicians to improve practices, undertake more detailed patient examinations with full documentation, and for Dr. Eedle to contact the hospital to improve post-operative patient care communication.

Action Planned (AI summary) Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and staff at the intermediate care facility can check the patient's prescribed medication by telephoning the discharging ward directly.

Action Planned (AI summary) AACE has been working with the NPCC, Home Office and the Department of Health to drive further improvements in both the speed of ambulance response and the proportion of patients conveyed by ambulance rather than police vehicles. The College of Policing, Health and Ambulance Service representatives are currently working together to devise a national protocol for the management of ABD in the pre-hospital setting. The Metropolitan Police national instruction is to monitor and review all service requests to mental health environments and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in health environment whatever the circumstances. Multi-agency membership includes NHS England, the Royal College of Psychiatrists, the Royal College of Nursing, and NICE. The Department published the Crisis Care Concordat in 2014 to ensure that anyone experiencing a mental health crisis receives the right support in the right place. The Department has also funded a number of street triage pilot schemes where mental health professionals provide on the spot advice to police when dealing with people with possible mental health problems.