East Riding and Hull

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) Hull University Teaching Hospitals acknowledges the coroner's concerns regarding discharge information, but clarifies that a Trusted Assessor Referral Form (TARF) detailing the patient's frailty and mobility was completed and submitted to Social Services. The hospital also noted the discharge summary included a request to the GP to follow up on blood pressure.

Noted (AI summary) NHS England refers to the RCOG guidance on assisted vaginal birth and highlights the need for clinicians to be aware of the guidance and assess the advantages and disadvantages of available delivery techniques; the results of the ROTATE trial will be carefully reviewed. Following inaccurate assessments of fetal head position by clinicians prior to starting procedures, RCOG advises that ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination. Updated RCOG Green-top Guideline No. 26 provides recommendations to support practitioners around the use of instruments for assisted vaginal births.

Noted (AI summary) The GPhC acknowledges receipt of the concern regarding Orchard 2000 Pharmacy and provides context about its role as a regulator of pharmacy professionals and premises, but does not describe any specific actions taken or planned in response to the concern. The GPhC notes concerns about the roles and responsibilities of delivery agents and states that the Superintendent Pharmacist has updated SOPs to clarify how delivery drivers should respond to emergencies, including contacting emergency services and informing the pharmacist. Delivery drivers are also enrolled on a specific training course. Orchard 2000 Pharmacy has made delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty in emergencies. They have also enrolled delivery agents in a training program titled 'Delivering Medicines Safely and Effectively'.

Noted (AI summary) TRL describes its role in supporting the SHARP helmet rating scheme and summarises existing research on helmet loss, concluding that more work should be done in light of changing motorcycle user demographics. They raise questions about the specific helmet and circumstances of the incident. The Department provides advice and guidance to motorcyclists through its Safety Helmet Assessment and Rating Programme (SHARP), including guidance on helmet selection and fitting on the SHARP website. DVSA's CBT syllabus includes helmet fitting and fastening, and examiners check helmet fastening. The Department will continue to review technical standards for helmets and promote helmet fitting and usage. The Forensic Collision Investigator provides information on the helmet involved in the incident and refers some queries to other agencies, stating the helmet met basic UK standards. They are unable to comment on how tightly the helmet was fastened when worn.

Noted (AI summary) The Ministry of Justice is working with the Home Office to prioritise commitments in the Tackling Domestic Abuse Plan, including investing over £230 million in tackling domestic abuse. They have also worked to improve probation staff awareness of MARAC and published a draft Victims Bill. The Home Office acknowledges the report and states that officials will provide a full response by the stated deadline. The Home Office highlights the Domestic Abuse Act 2021, its statutory guidance published in July 2022, and the cross-Government Tackling Domestic Abuse Plan published in March. The plan includes funding, model policies, training and awareness packages. The Department of Health and Social Care is working with the Home Office on the Tackling Domestic Abuse Plan and will include measures to tackle domestic abuse in the national suicide prevention strategy. Integrated care boards are required to set out how they will address the needs of victims of abuse and NHS England is developing guidance to assist them.

Noted (AI summary) The RCPCH acknowledges the concerns and will share the report with its Quality in Clinical Practice committee for further discussion to identify opportunities to prevent future deaths, and will continue to collaborate with the RCGP on safe and effective pathways of care for children and young people, ensuring the child health workforce is represented in national discussions on children’s urgent and emergency healthcare, and patient safety. The RCGP acknowledges the concerns, outlines educational material for GPs in training, and welcomes changes to the 111 out-of-hours algorithm. They support investment in primary care infrastructure to improve data sharing, but note that dissemination of a rare case report is not currently considered necessary. NHS Digital reports that the 111 algorithm was modified and provides detail on the governance structure overseeing NHS Pathways, including independent oversight, consistency with NICE guidelines, and a process for reporting incidents and requesting changes.

Noted (AI summary) The council acknowledges the concerns raised but asserts that Hook Lane/Westfield Lane is not a "black spot" and that previous collisions were due to driver error or pre-existing illness. They will continue to monitor the route for flow, speed and injury collisions and take future action as appropriate.