East London

Action Planned (AI summary) Barts Health NHS Trust's Haemoglobinopathy Coordinating Centre (HCC) is developing a website with information to support families and has appointed a governance lead to lead on network wide quality improvement and governance. They are also involved in an exhibition to challenge staff attitudes and behaviours towards patients. Maylands Healthcare has undertaken an annual audit of patients with Sickle Cell Disease, proactively contacts them for medication reviews, liaises with specialists, changes medications to electronic repeat dispensing, and shares learning points from Significant Event Analyses with staff. They have also added clear alerts in each clinical record and all clinical staff have undertaken mandatory Sepsis training. The Department of Health and Social Care has introduced an incentive for GPs to identify patients who would benefit most from continuity of care, and has implemented "Jess's Rule", encouraging clinicians to re-evaluate symptoms if a patient's condition remains unresolved after three consultations. NHS England is also working to improve education and awareness of sickle cell disease amongst healthcare staff and for patients and carers. Partnership of East London Co-operatives (PELC) has shared organisational learning regarding the importance of reviewing patient records and included this requirement in staff contracts. They are also implementing an alert within clinical records for all children presenting with sickle cell disease.

Action Planned (AI summary) Barts Health acknowledges failures in governance and is commissioning an Independent Review of governance processes related to Patient Safety Incident Response Framework (PSIRF), including decision-making at Patient Safety Incident Review Meetings (PSIRM).

Action Planned (AI summary) Whipps Cross Hospital will ensure families are contacted as part of the Patient Safety Incident Review Meeting (PSIRM) process. The Trust has also commissioned a review, to be completed by the end of August 2025, of the governance processes relating to this case with engagement from the Foster family. The Department of Health and Social Care notes that the North London Integrated Care Board, supported by NHS England, will review the governance processes related to the case to identify areas for improvement, with the review to be completed by August 2025.