Cambridgeshire and Peterborough

Action Planned (AI summary) NHS England and NHS Improvement will send a communication to mental health trusts to bring their attention to the risks associated with sodium nitrate as a means of suicide and the need to seek advice from the National Poisons Information Service (NPIS). The Department of Health and Social Care is working with other government departments, health bodies, and experts to tackle the use of sodium nitrate and similar chemicals in suicides. The Royal College of Psychiatrists will look for opportunities to reinforce key risk advice around sodium nitrate and other substances to psychiatrists and will ask those responsible for treatment in Emergency Departments to consider adding mention of sodium nitrate to toxicology sites used by clinicians.

Action Planned (AI summary) The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients.

Action Planned (AI summary) NHS England and NHS Improvement are improving adult eating disorder services with a national programme backed by investment. They are also improving data on the prevalence of eating disorders in adults, joining the APMS steering group to influence questionnaires. The GMC has used its regulatory powers to address inconsistency in training to address patient safety concerns, and is working with medical schools to ensure ED training is delivered more consistently. A new e-learning programme for medical students and foundation doctors has been launched, and existing curricula have been updated. The Department of Health and Social Care acknowledges concerns about eating disorder treatment and highlights the Mental Health Recovery Action Plan, which includes significant funding to expand children's and adult mental health services, including eating disorder services. HEE has a range of high quality training available via its e-Learning arm, e-Learning for Healthcare, around eating disorders, particularly on its MindEd programme, which is targeted at professionals and their families. This training includes a new programme for medical students and foundation doctors, developed in partnership with RCPsych and the eating disorder charity, Beat.

Action Planned (AI summary) Defra is revising the Secretary of State’s Standards of Modern Zoo Practice (SSSMZP) with expected consultation over the summer and publication by the end of 2020, to address concerns and place clear, legally enforceable obligations on zoos. Defra has undertaken a targeted consultation on draft new Standards of Modern Zoo Practice for Great Britain, addressing the need for clearer guidance and robust inspection processes. The new standards will come into effect on 23 May 2027 and will require zoos to have documented safe systems of work and regular staff training for those working with Category 1A, Category 1 or Category 2 listed animals.

Action Planned (AI summary) The RCoA, AAGBI and DAS will publish articles and highlight the importance of capnography in the Safe Anaesthesia Liaison Group's Patient Safety Update, Anaesthesia News and the DAS newsletter. The RCoA's Simulation Working Group will consider creating guidance on crisis simulation for operating theatre teams. North West Anglia NHS Foundation Trust is planning simulation training for anaesthetists, commissioning human factors training, and undertaking a SCORE cultural survey, with a timescale for completion by the end of March 2018. Since June 2016, many substantive appointments have been made to the cadre of Consultant Anaesthetists at Hinchingbrooke Hospital. NHS Improvement added 'undetected oesophageal intubation' to their Never Event Framework in February 2018, and is developing national guidance in collaboration with relevant organisations. The RCoA's CPD includes training on perioperative emergencies and human factors.

Action Planned (AI summary) The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR investigation. They have developed a 'Learning from Deaths' policy to respond to and learn from deaths of patients under their management. The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend to take. They are planning to inspect specific core services at BHRUT in the first part of 2018, including a 3-day in-depth inspection of the leadership and governance of the trust. NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next 6 months, focusing on treating patients with raised intracranial pressure and urging extreme caution in relation to the use of opiates. NHS England will also seek assurances from the Trust that they have addressed the concerns raised and will suggest an independent review of the case management.

Action Planned (AI summary) East of England Ambulance Service is reviewing the East Midlands Ambulance Service's Paramedic Pathfinder Programme to determine its potential implementation within the Trust and implications for current training.