Brighton & Hove

Action Taken (AI summary) The Trust has strengthened internal monitoring, enhanced training (including for agency/bank staff), and now reviews policy compliance weekly by the Ward Manager and monthly by the Matron. They are also undertaking a Quality Improvement programme for therapeutic observations and considering technological aids for patient monitoring, expected to be completed by December 31st, 2021.

Action Taken (AI summary) Western Sussex Hospital Trust shared the PFD report with relevant staff, conducted an RCA, and confirmed a Trust Surgical Board ratified Transfer Policy is in place for complex trauma patients needing specialist surgery at the Major Trauma Centre. They also included the application of spanning external fixator, elevation, and early mobilisation within the protocol.

Action Taken (AI summary) The Trust disputes that lessons haven't been learned regarding NEWS, citing the implementation of electronic patient observations (Patientrack) in all adult and paediatric inpatient areas since July 2019, with Maternity and ED to follow. All Radiologists have been reminded to look at the SMA, the protocol has changed to enable better visualization and overnight scans are reviewed by a Consultant the following morning.

Action Taken (AI summary) The Trust has already taken several actions, including ensuring compliance with NICE guidelines for allergy management, incorporating a reaction tool into prescription charts, rolling out an electronic NEWS recording system, expanding the Critical Care Outreach service, and reviewing practices for preventing fatigue in junior doctors.

Action Taken (AI summary) Police CCTV operators will now scan for water safety equipment as part of the initial response where someone has entered the water. Sussex Police will be supporting the summer 'Keeping safe campaign' which includes water safety advice, highlighting the dangers of entering the sea when under the influence of drink/drugs or in adverse weather conditions.

Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust has shared the inquest findings widely within the Trust, appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning and the discharge planner template is being revised to make it clearer and easier to use and record the key information.

Action Taken (AI summary) Brighton and Sussex University NHS Trust conducted team meetings and a Serious Incident Review Meeting to address inadequacies in the patient's care. They issued a Trust Safety Alert instructing staff not to use the 'once-only' section of the drug chart for infusions, and implemented a new system for Acute Medicine Consultants to cover telephone calls.

Action Taken (AI summary) The Commissioning Alliance reports that changes have been made to IT systems to flag up early ordering of scripts, arrangements have been made to ensure staff have time to manage prescription requests, and access to online requests for repeat prescriptions of opiates and other drugs of dependency have been removed. They are also providing ongoing support around embedding a High Risk Drug review protocol. North Laine Medical Centre has updated its repeat prescribing policy, including tighter controls on controlled drug prescriptions, changes to computer settings to flag early script requests, and new procedures for uncollected prescriptions. They have also re-circulated existing guidance. Brighton and Sussex University Hospitals has fed back concerns about discharge summaries to the Clinical Director for Emergency and Acute Medicine and the Consultant and Governance Lead for Emergency Medicine, who have discussed the issues with medical staff. They also plan to implement systems within the next 12 months to allow discharge letters and summaries to be sent electronically.

Action Taken (AI summary) The Trust will not accept bookings for major urology cancer surgery patients on the private patient unit. The urology specialty will conduct documentation audits to identify themes and improvements, and agree a process for ensuring Electronic Discharge notification is signed/checked by a senior doctor.

Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust has circulated a message to staff about correct containers for sterile body fluids, altered the lab SOP to include an educational message when the wrong container is received, and discussed the case at a clinical governance meeting to improve prioritization of urgent follow-ups.

Action Taken (AI summary) Brighton and Sussex University Hospitals NHS Trust held study days for nurses on LBAW covering topics including Deprivation of Liberty, falls prevention, one-to-one care, and end of life care, after the inquest. An audit has been carried out of every patient specialled and the findings are being collated for action.