Essex

Noted (AI summary) Affinity Water expresses condolences and describes existing safety measures and a commitment to zero harm. Following the death, they reviewed and strengthened traffic management practices and implemented stricter oversight of contractors, resulting in a reduction in street works requiring emergency permits; they also enhanced permit application processes, including additional resourcing, improved communication, and reinforced training. The Department for Transport expresses condolences and notes that road safety is a high priority. It describes the role of the Safety at Street Works and Road Works Code of Practice and that the code is currently being updated with a consultation planned for early summer and publication by the end of 2025, taking the coroner's report into account. Hatton Traffic Management undertook a full review of emergency works procedures, resulting in new design layouts for all traffic light schemes which were rolled out across the business. A specific toolbox talk addressing this issue and the above changes, was devised and rolled out across the business. Essex County Council explains its role in regulating street works, noting limitations in refusing permits and the use of the Street Manager system. They will raise the lack of incident reporting in retrospective permit applications with the Department for Transport.

Noted (AI summary) NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe internal processes for reviewing PFD reports. The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also provided guidance on assessing patient capacity and detaining patients under Section 5(2) of the Mental Health Act, including notification procedures and patient rights. The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A Joint Working Protocol is being put in place and the SLA between MSE and EPUT is being addressed at a senior level.

Noted (AI summary) NHS England acknowledges the concerns raised but states that they fall under the remit of East Suffolk & North Essex NHS Foundation Trust; they note that the Trust has taken learnings and is taking actions to ensure staff have Immediate Life Support training and that Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group. East Suffolk & North Essex NHS Foundation Trust has implemented actions including mandatory immediate life support training for certain staff, and monthly quality audits of resuscitation trolleys.

Noted (AI summary) NHS England acknowledges the concerns regarding neurology department pressures and neurologist shortages. They highlight the GIRFT program and national work on workforce wellbeing, but note that safe staffing is the responsibility of individual trusts. They are engaging with the Mid and South Essex NHS Foundation Trust regarding their Serious Incident Review and action plan. The Trust acknowledges concerns around delays in neurology referrals and inappropriate telephone consultations during the pandemic, but attributes some issues to external services and COVID-19 restrictions. They have undertaken several actions, including policy reviews, audits, training, and investment in neurology services to address these issues. They have also reached out to NHS England about the shortage of neurologists and are waiting for national guidance.

Noted (AI summary) Skills for Care recommends that every frontline care worker within a CQC regulated service should receive First Aid training, including basic life support as part of their initial induction to the sector, and ensure these skills are regularly refreshed. They highlight existing guidance and initiatives, but note that they cannot mandate training. Peabody has improved its training program for care workers in supported living environments, now requiring certified First Aid and Basic Life Support training before solo work. Existing care workers will also complete the new course within one year and the organisation has launched an Ofsted-registered Academy. CQC acknowledges the regulation regarding staffing qualifications and training and highlights that Peabody has revised protocols to ensure no support worker lone works without enhanced training in emergency first aid and basic life support, and is ensuring appropriately trained personnel on every shift. CQC will be considering the case under its framework for health and safety incidents.

Noted (AI summary) The Ambulance Service has disseminated posters addressing human factors, developed a new training package on decision-making under pressure, and is providing regular updates on best practice for asthma management. They have removed the skill of intubation for general paramedics and are rolling out Advanced Paramedics in Critical Care cars across the region. They have also implemented the Patient Safety Improvement Response Framework. Mid and South Essex NHS Foundation Trust has shared learning with teams about the JRCALC protocol on managing severe asthma in children and is delivering training sessions focusing on the role of Adrenaline; they have also sent an email to staff regarding the use of Adrenaline in pre-hospital asthma resuscitation. AACE will review the JRCALC asthma guideline and make changes if required, and will share the concerns with their national ambulance service medical directors’ group (NASMeD) to consider further education or awareness for clinicians regarding airway management and adrenaline administration. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. The Department acknowledges the concerns and describes the existing framework for healthcare professional training, including the National Capabilities Framework for Professionals who care for Children and Young People with Asthma. They note that employers are responsible for ensuring staff are trained to the required standards.