Cambridgeshire and Peterborough

Noted (AI summary) The Partnership acknowledges the concerns but cannot comment on the specific reasons for the original CDOP decision due to missing documentation. It provides assurance regarding the current child death review process, including improved data storage, family involvement, and panel operations. The Royal College of Radiologists acknowledges the concern, highlights the shortage of radiologists in the UK and the importance of written evaluations of imaging, and supports regional imaging networks to enable equitable access to expertise and resources. While willing to raise cardiac screening with England Boxing, the department is unable to provide additional funding. They highlighted existing support for Cardiac Risk in the Young through Sport England. The Royal College of Emergency Medicine acknowledges the concerns and provides context regarding the clinical management in the case. It references existing curriculum and resources related to the issues raised, but describes no specific actions taken or planned. The ICB will seek assurance of compliance with 'Shock to Survival' recommendations through Clinical Quality Review Meetings with relevant providers. It will also have access to GENOME dashboards to monitor patient safety surveillance and track progress against quality priorities. The Trust highlights several changes and quality improvements already made since the incident, including a new escalation process ('Martha's Rule'), a weekly meeting to discuss potentially harmed patients, and reviews by the CQC. All recommendations from previous Regulation 28 reports have been actioned. The Faculty of Intensive Care Medicine acknowledges the concerns, explains the role of focused echocardiography in intensive care, and highlights curriculum updates and guidelines supporting its use. They also express support for reliable provision of emergent echocardiography and image storage, but do not commit to specific actions. NHS England and the British Heart Foundation co-funded a sudden cardiac death pilot to develop mechanisms for post-mortem genetic testing, best practice pathways and engagement with patient groups. They also expect NHS Trusts to ensure protocols are appropriate in the wake of the death.

Noted (AI summary) NHS England notes the concerns about non-uniform hospital discharge notes and highlights the existing national guidance and role-based action cards. They state that Royal Papworth Hospital has improved processes for updating next of kin on patient transfers and that the Regulation 28 Working Group discusses reports to identify emerging trends. The DHSC acknowledges the concerns and refers to national statutory hospital discharge guidance, noting that individual trusts are responsible for their own discharge policies. They welcome the steps taken by the Royal Papworth Hospital NHS Foundation Trust around involvement of next of kin in patient transfers.

Noted (AI summary) The Department of Transport acknowledges the coroner's concerns regarding cluster sites and GPS routing but states that decisions about highways maintenance and enforcement are the responsibility of local authorities and that drivers should prioritise road signage over GPS guidance. Cambridgeshire County Council plans to implement a 30mph speed limit (with 40mph buffer zones) on Puddock Road by the end of November 2024, conduct a traffic flow survey in early November 2024, and undertake informal engagement on road closure/restricted access, followed by a formal Traffic Regulation Order application and consultation.

Noted (AI summary) NHS Cambridgeshire and Peterborough Integrated Care Board have signposted all GPs working for the NHS within to guidance on detection of skin cancers, reminded them to refer any skin lesions where there is diagnostic uncertainty, and reminded all services that they commission in primary care that excised skin lesions should be sent routinely for histology. NHS England stated that the ICS have reminded all GPs within Cambridgeshire and Peterborough Integrated Care System of the guidance on skin cancers, shared the benign skin lesion policy, and reminded their NHS primary care commissioned dermatology services of the guidance on techniques and facilities for conducting minor surgery. The Department of Health and Social Care acknowledged the concerns and stated that NHS England has responded to the coroner in detail. They reiterated the importance of patient safety and the role of the Care Quality Commission and General Medical Council.

Noted (AI summary) NHS England has commissioned a review of HTM 04-01 by Dr Susanne Surman-Lee, specifically related to immunosuppressed patients and NTM, including identifying any specific measures required for new hospital premises, and a gap analysis between British Standard BS 8580-2:2022. They aim to publish a technical bulletin with any amendments by Spring. The Department of Health and Social Care acknowledges the concerns and states that NHS England is the correct organisation to respond, noting that NHSE already sent a response on Feb 6, 2023.

Noted (AI summary) The Department acknowledges the concerns regarding the 2010 Risk Assessment Tool for Venous Thromboembolism (VTE) and refers to NICE guidelines. They note the need for further research to balance VTE risk versus bleeding risk in acute psychiatric settings and that the National Patient Safety Committee will work to identify the best route to take this forward.

Noted (AI summary) NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing NICE and GMC guidance on sharing information and safe medicine use. The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health records and safe transfers of care. The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share learnings from the case with stakeholders and encourage pharmacies to work more effectively with healthcare teams. The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, RPS, and NHS England) to consider how practice can be improved.