East London

Noted (AI summary) The Trust will not allow removal or deferral of cancer patients on a Patient Tracker List without consultant approval. A restructure of cancer administration pathways is underway and an external review of controlled medication practices is planned. The Trust has changed the process of Controlled Medication Keys and is trialing a digital key system and exploring installing CCTV. The MHRA acknowledges the concerns but states they cannot comment on medical advice or care quality. They explain the MHRA's role in assessing medical devices and note they received a previous NRLS report regarding a gastrostomy balloon device, but the investigation was closed in August 2023 due to the implementation of ENFit standards. The DHSC acknowledges the concerns regarding the care provided by the Trust and its processes. It outlines the roles of NHS England, CQC and MHRA and refers to NICE guidance and NIHR funded studies on sepsis.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the matters are primarily local issues for Barts Health NHS Foundation Trust to address. Barts Health acknowledges documentation issues and is planning several actions including consultant re-induction, audits, training on capacity assessment and sedation, and recruitment of a learning from deaths lead.

Noted (AI summary) NHS England acknowledges the concerns regarding epilepsy patient reviews and medication management, highlighting existing NICE guidelines, RCGP eLearning resources, and tools for structured reviews. They note workforce capacity challenges and share the report with regional colleagues, also describing the Regulation 28 Working Group. The Royal College of Physicians supports the Association of British Neurologists' position regarding national guidance on epilepsy monitoring, annual follow-up in primary care, and the need for clear communication in discharge letters. They highlight the low number of neurologists and epilepsy specialist nurses in the UK. The RCGP plans to highlight NICE guidelines and educational material on SUDEP through its Clinical Networks and member forums. It will also recommend to NHS England the need for standardised urgent care pathways for epilepsy patients and address issues relating to waiting times for appointments.

Noted (AI summary) Outlook Care has implemented an action plan including external feedback, stakeholder inclusion in reviews, and collaborative working with LBWF. They've revised their Missing Person policy, provided staff training, and conducted spot checks on 1:1 support, issuing guidance on maintaining a 'line of sight'. Future actions include business continuity tests, audits of risk management, and revised induction formats. The CQC reviewed information on Waterside Lodge Recovery Centre and requested a copy of Outlook Care's response to the coroner, noting changes across their remaining nine locations including review of missing person policy, training for staff, additional risk assessments and spot checks on community visits, and will request and review evidence of completion of these actions. The Metropolitan Police state that they have been unable to identify any other deaths in the area that would suggest any specific or ongoing risk to public safety, or significant criminal activity. They confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping and have increased engagement with local residents to encourage reporting of rough sleeping. The London Borough of Waltham Forest explains its processes for monitoring commissioned supported living services and managing parks/open spaces. They state that the support worker was not employed or commissioned by them. They outline referral pathways for vulnerable adults, rough sleeping monitoring, and vegetation management but do not commit to specific changes.

Noted (AI summary) NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for young people up to 25, and existing guidance for GPs. Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information sharing, and safeguarding training as part of their professional training.

Noted (AI summary) Wood Street Health Centre audited patients prescribed Zopiclone/Zolpidem, is reviewing their medication, has moved to acute prescriptions only (max 2-week supply), instructs 'as required' use on prescriptions, informed local pharmacists, and prepared a new shared care policy; 69 patients have had their medication stopped. North East London NHS Foundation Trust (NELFT) audited prescribing practice and revised its prescribing policy for hypnotics, is participating in a working group to improve medication monitoring across primary and secondary care, increased staffing in Crisis and Home Treatment teams, and ensured comprehensive documentation of patient information at handover. The Department of Health and Social Care acknowledges the concerns raised and notes that NHS England is working to support prescribers in managing repeat prescribing; it also acknowledges actions being taken by Wood Street Health Centre and North East London NHS Foundation Trust.

Noted (AI summary) NHS England is increasing access to CYPMH services, with 702,000 children and young people receiving support in the 12 months to June 2023 and a 46% increase in the CYPMH workforce since the start of the LTP. They will also ensure regional leadership are aware of the report's findings and the Regulation 28 Working Group will discuss all reports received. NELFT will implement the Oxford Centre for Suicide Research’s model of risk formulation and co-produce safety plans with clients and families, including training and system changes to support the roll out. NHS North East London is developing a business case for additional CAMHS funding, including proposals for seven-day/evening working and face-to-face initial assessments. They are also reviewing the current clinical model and participating in transformation work via their Mental Health, Learning Disability and Autism Collaborative. The Department of Health and Social Care acknowledges concerns about CAMHS resourcing and highlights increased spending on mental health services and workforce development initiatives, including training programmes and a new suicide prevention strategy.

Noted (AI summary) The Trust is implementing a fully electronic outpatient outcome system and rolling out LUNA, a digital monitoring tool for patient tracking lists, expected by the end of September 2023. They have sought expert advice regarding limitations of the VTE risk assessment and will continue to monitor information from national bodies. The Department acknowledges the concerns raised, notes the actions taken by the Trust, including implementing a digital monitoring tool and seeking expert advice on VTE risk assessment, and refers to broader government efforts to advance patient safety.