Black Country

Noted (AI summary) • A formal written response has been sent to Mrs Rhodes offering condolences, setting out the circumstances as understood by the Practice, and detailing the system-level changes implemented following review. • The Practice has also offered to meet with Mrs Rhodes in person to discuss the matter further should she wish to do so. • The Practice has engaged openly and transparently throughout the coroner’s investigation and will continue to do so.

Noted (AI summary) • NHS England has produced a national framework and operational guidance for autism assessments. • The operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments. • Birchills Health Centre reviewed J.A’s case in a clinical meeting on 19.01.2023 and more recently on 02.02.2026 as part of their child protection meeting. • Birchills Health Centre identified that more comprehensive record keeping including clearer details of fluid intake should be recorded in assessing any child with risk of dehydration. • Birchills Health Centre had a presentation on identification of dehydration in children to help remind clinicians on most effective ways of assessing hydration status.

Noted (AI summary) Wolverhampton NHS Trust states that it does not provide direct mental health services, but refers patients to the Black Country Healthcare NHS Foundation Trust. They outline the referral process to the Mental Health Liaison Service and state that appropriate referrals were made in this case. West Midlands Police has implemented actions including the development of additional guidance for officers regarding mental health assessments, a review of risk assessment documentation, and ensuring access to Summary Care Records for healthcare providers in custody suites. They are working with mental health trusts to improve mental health service provision in custody.

Noted (AI summary) Walsall MBC acknowledges the concerns regarding pedestrian safety near a parade of shops, but cites legal and practical difficulties in implementing the suggested measures, including land ownership and the need for third-party consent; they are considering alternative measures but cannot guarantee their adoption.

Noted (AI summary) West Midlands Ambulance Service acknowledged the ECG was abnormal and that policy wasn't followed; clinicians received a case review, participated in a Serious Incident process, completed reflective practice, and are scheduled for additional ECG/ACS training. Additional actions include updating policies and providing additional equipment/training to improve chest pain management and ECG interpretation. The Health and Care Professions Council acknowledges the concern but states that the individual in question is not registered with them, so the concerns do not fall within their remit for further investigation, but the individual's name has been added to a watchlist. The Health Services Safety Investigations Body is undertaking exploratory work regarding paramedic interpretation of ECGs in the community and will consider the scope for a formal investigation by the end of January 2024. The University of Wolverhampton will present case evidence to students, incorporate ECG interpretation into Objective Structured Clinical Examinations, liaise with coronary care units for anonymised ECG readings, add an ECG interpretation workbook to the virtual learning environment, and organise continuing professional development ECG masterclasses. The CQC has reviewed WMAS's actions following the death and found no evidence of provider-level failings, although they identified concerns regarding the timeliness of addressing the training needs of staff involved. The training needs of one staff member have been addressed, and the second staff member's training will be met upon their return to work.

Noted (AI summary) The organisation states that it had received public health advice about how to manage the pandemic and balanced obligations to licensees and employees, and maintenance staff were not put on furlough because of income streams. It has undertaken PAT tests and the organisation will be guided by advice received from several agencies including Public Health England and the Fire and Rescue Service to determine its plan on managing any increased risks posed by the absence of PAT testing.

Noted (AI summary) The Department acknowledges the concerns about DVT risks with risperidone and highlights existing NICE guidance and QOF checks for patients with SMI and notes local actions taken by the Black Country Healthcare NHS Foundation Trust. The Trust concluded that ambulance service is responsible for providing extrication equipment, but will include confirmation if a patient is bariatric, in a confined space or on the first floor in future training and an email will be sent to all staff to ensure awareness.

Noted (AI summary) The CQC acknowledges the PFD report and details actions taken following a notification of death and whistleblowing concerns, including an inspection and review of falls management. They will continue to monitor information received about the service until the next inspection. Castlehill Specialist Care Centre has fitted individual door sensors in every bedroom, installed new monitoring screens linked to the external doorbell, and will make 111/999 calls following any fall. They will also raise safeguarding alerts and request 1:1 funding following any fall.

Noted (AI summary) West Midlands Ambulance Service took immediate action by informing all frontline staff of requirements for medical gas cylinder assembly/disassembly and sharing lessons learned with partner organizations. The CQC acknowledges the concerns but states it is outside of their remit to issue or change formal guidance or policies around oxygen usage or safety, as they are not clinical experts. They will continue to communicate with WMAS and monitor actions taken to improve safety. HSE will support MHRA as the lead authority and will use its communication channels to promote any information/guidance produced by the MHRA. They will also consider if HSE guidance document INDG459 should be updated to reflect any new information/guidance produced. MHRA has commenced a dialogue with the Association of Anaesthetists and the Safe Anaesthesia Liaison Group of the Royal College of Anaesthetists to raise awareness of ignition within valve components of oxygen cylinders. MHRA was represented on a multiagency group which hopes to publish guidance once ratified by the Councils of both the RCoA and the AA.

Noted (AI summary) BCPS is implementing audit processes for the routine review of malignant cases in preparation for MDT meetings, and modified Southampton audits. They will also improve pathways to notify BCPS of increasing cancer work. A consultant histopathologist post will continue to be advertised. Actions are to be completed by 31 May 2020. The response forwards information from Black Country Pathology Services and The Royal Wolverhampton NHS Trust relating to previous concerns. It notes that the patient was under the care of Walsall Healthcare NHS Trust. The Trust will develop a Community Standard Operating Procedure for VTE risk assessment and prophylaxis for specific patient groups, and will liaise with the CCG regarding procedures in Care Homes. Completion is expected by 31 October 2020.