East London

Noted (AI summary) The MHRA will engage with the medical device safety officers (MDSO) network to raise awareness of possible incidents involving filters and encourage reporting and will write to known manufacturers of filters to ask them to conduct a review of the labelling of filter devices against the regulatory requirements, taking into consideration the findings of the inquest, and making improvements where identified. The response provides background information on HME/filters, potential issues, and proposes solutions such as standardized color coding and clearer labeling, but does not commit to any specific action. The organisations will highlight key lessons about breathing circuit filters to their membership through the Safe Anaesthesia Liaison Group’s Patient Safety Update and FICM Safety Bulletin, and have suggested that NHS Improvement undertake a formal analysis of the NRLS database to assess the frequency of incidents arising from incorrect filter use. The MHRA will work with manufacturers, other regulators, NHS England and Improvement and other stakeholders to explore the effects of actions such as reducing filter types and improving color coding, and will engage with the medical device safety officers (MDSO) network to raise awareness and improve incident reporting.

Noted (AI summary) The Metropolitan Police Service will develop additional training on recording property, especially regarding risk, and implement it in the "Street Duties" course for probationer constables. The officer involved in the incident has been spoken to and advised on recording property and circumstances for seizure. The Trust has discussed the concerns with Borough Lead Nurses and sent letters to nursing staff, highlighting expectations for patient searches, observations, and rapid tranquilisation monitoring. The Trust now requires formal training and competency assessment for staff conducting searches and observations, with Registered Nurses exclusively performing RT monitoring within eyesight for the first hour post-administration. The Department acknowledges the concerns and outlines actions taken by the East London NHS Foundation Trust (ELFT), NHS England and NHS Improvement (NHSE & NHSI), and the Care Quality Commission (CQC). It highlights ongoing monitoring and planned inspections of ELFT.

Noted (AI summary) The Royal College of General Practitioners explained the current system for transferring GP records, supporting electronic transfer (GP2GP) for its advantages. They clarified that the responsibility for the transfer system lies with Primary Care Support England, not the RCGP itself. Barking, Dagenham, Havering and Redbridge CCG and NELFT have implemented changes to the Psychological Therapies service, including updating standard operating procedures, increasing service capacity, and reviewing panel protocols to manage risks associated with waiting lists. They are also planning a formal service review and considering further investment.

Noted (AI summary) The Clinical Commissioning Group has already introduced changes to the process of requesting 1-to-1 care by care providers in November 2020, including routing requests to a senior nurse assessor for a response within 2 hours and requiring further evidence for extensions. They are also adding a safeguard to ensure that requests for 1 to 1s are submitted to the brokerage team and are escalated to a senior clinician, to be built into their electronic systems by the end of February 2021. The Department of Health and Social Care acknowledges the concerns raised and states that the CCGs are responsible for commissioning 1:1 care and have provided a response detailing actions taken. The Department will work with NHS England to consider the circumstances of the case but does not consider a change in national policy is required.