East London

Action Planned (AI summary) NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues to discuss prescribing of medication to shared patients.

Action Planned (AI summary) The surgery will conduct a survey of visit requests by the home and seek feedback on how to improve the process. They have a lower threshold for home visit requests from this Home given that the information given on the telephone by carers may not reflect the true health needs of residents.

Action Planned (AI summary) North East London NHS Foundation Trust is undertaking a series of actions including sending FOI requests to other trusts, reviewing and updating S136 guidance and policy, creating a secure NHS net account for the S136 suite, and holding a board workshop to discuss SI investigations. They will also explore inviting the Senior Coroner to deliver a presentation. The Borough Mental Team has identified four areas for improvement: handover of patients between the police and 136 suite staff; filing and storage of 136 paperwork; supporting officers dealing with 136 incidents; and training. Changes to Form 434, a review meeting planned for early February and a video presentation with Mrs Persaud for training are planned.

Action Planned (AI summary) The Trust states it has carefully considered the report and is fully cognisant of the issues and committed to continuously review its service and has enclosed the Trust's action plan to prevent the reoccurrence of the shortcomings identified in your Regulation 28 report

Action Planned (AI summary) NELFT and CCGs will review care pathways for patients with anti-social personality disorder, ensuring support to access existing services per NICE guidelines and develop a communication plan. The review, commencing in May 2016, aims to identify service gaps and consider developing local personality disorder networks, with completion expected by 30 September 2016.

Action Planned (AI summary) The Pharmacy department at Barts Health NHS Trust is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity, and a 'share the learning' bulletin. Newham University Hospital is planning to review Serious Untoward Incidents reported from 2013 to date to identify if there are any opiate related SUIs and is retraining all nursing staff.

Action Planned (AI summary) NELFT developed an action plan with five broad objectives addressing concerns about assessment, communication with carers, procedures, record keeping, and risk assessment.

Action Planned (AI summary) The Metropolitan Police Service will implement mandatory refresher training for communications officers on the Merlin database by March 31st 2016, focusing on the 'red flag' marker and incident reports. Line managers have been instructed to monitor training completion.

Action Planned (AI summary) Handicare has adjusted internal processes and training for in-house engineers. It will also raise the issue of sharing safety information with all manufacturers at the next BHTA stairlift section meeting and via letter during the week commencing 15th June 2015. BHTA will remind manufacturer members to continue training to address field safety issues until all products have been traced and necessary action taken. BHTA will recommend that the Health & Safety Executive talk to the MHRA and see if they might tap into the alerting system for alerts regarding products sold into the care sector.