Manchester North

Action Planned (AI summary) Greater Manchester Mental Health NHS Trust has replaced the Recovery and Discharge Plan with the ATAC care plan, developed a care bundle to improve observations, updated its policy regarding patient observations, and provided training on observation standards. NHS England is running Proof of Concepts to expand Summary Care Record access to private hospitals and healthcare services, with learnings to be reported to an Expert Advisory Committee for potential full rollout approval.

Action Planned (AI summary) The trust outlines actions taken and planned including; sharing learning from the inquest, increasing access to safeguarding professionals, implementing PARIS for electronic patient records, distributing the Oldham Adults Safeguarding Board Self-Neglect toolkit and a recommendation to the Oldham Safeguarding Adult Partnership Board to develop a multi-agency protocol.

Action Planned (AI summary) Greater Manchester Mental Health NHS Trust is implementing a new electronic patient record system, undertaking a thematic review of observation audits, and reinforcing the availability of additional staffing resources to ward-based staff via the Duty Manager and on-call systems. NHS England has commissioned an external Independent Review of services and culture at Greater Manchester Mental Health NHS Foundation Trust, and will publish the findings; they also discuss all Regulation 28 reports at a national level to identify learning and emerging trends.

Action Planned (AI summary) Learning from the case will be presented to the Greater Manchester System Quality Group and cascaded to professionals through governance forums. The Regulation 28 report will be shared with mental health commissioners to ensure a review of older adult inpatient provision.

Action Planned (AI summary) The Department of Health and Social Care notes that Pennine Care Foundation Trust has implemented a shared electronic system across services (except IAPT) and recommends uploading Mental Health Act documentation into patient records. They will also consider including specific time periods for producing notes of assessments in the revised Code of Practice. A mental health assessment recording act template has been created for Section 12 doctors to complete, requiring rationale for not making a recommendation. All AMHPs now complete a social circumstance report when the decision is made not to detain a patient. The Royal College of Psychiatrists will use communication opportunities to remind members of the need for consistent and comprehensive recording of all clinical contacts, including those related to the Mental Health Act.

Action Planned (AI summary) The Trust will update the nursing admission proforma as part of the Electronic Patient Record (EPR) Programme roll-out to ask whether the patient has previously experienced any choking episodes, with implementation planned for Spring 2023.

Action Planned (AI summary) The Trust has drafted a process for requesting second opinions from consultant psychiatrists, healthcare professionals, patients, families, and carers which will be submitted to the Trust's Quality Group for scrutiny and sign-off and implemented across Pennine Care NHS Foundation Trust's services. They are also working to improve adherence to the Triangle of Care standards, including surveys, workshops, and relaunching the program trust-wide.

Action Planned (AI summary) Greater Manchester Police acknowledges concerns about the use of PNC markers and ANPR data. They are reviewing the use of high priority markers for vulnerable missing persons and are working to connect to the new National ANPR Service.

Action Planned (AI summary) Highways England will brief North West Highways England Regional Operations Centre staff and police officers on using 'free text' entries in incident logs, shared with all Regional Control Centres as best practice nationally. They maintain their existing policy for activating warning signals is robust and appropriate, and will not take further action on it. Highways England and the NWMPG have agreed to add a free text description to the log to clearly identify the source of information. Police operators and supervisors within NWMPG will be briefed to add this plain language to logs, with a briefing note circulated to staff.

Action Planned (AI summary) Greater Manchester Police is working towards an electronic information sharing system with NWAS to improve communication, and plans are in place to develop a training package for OCB staff including clear instructions regarding information sharing with NWAS. NWAS states that a referral process was only due to go live in 2021, but has been brought forward in light of the current COVID-19 pandemic. The current process is that NWAS Clinical Hub will identify two mental health incidents per hour from 999 or 111 that are either a Category 3 or Category 4 mental health incident.

Action Planned (AI summary) NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system.

Action Planned (AI summary) The Trust has implemented measures to improve ambulance turnaround times, including daily meetings to review patient flow, screens displaying ambulance information, purchasing additional trolleys, and having Ambulance Liaison Officers on site during high demand. The Trust also joined a Phase 2 NWAS ambulance handover collaborative project. Blackpool CCG emphasized a Roster Review in commissioner requirements and are involved in initiatives to improve hospital handover times by using improvement methodology with several hospitals. They are also part of a North West Handover Improvement Board. NWAS is trialing a pilot program in the Cheshire and Mersey EOC to manage meal breaks differently, involving a mandatory staggered stand down of resources. They will also be adding 250 paramedics to the service by March 2020. The Department of Health and Social Care outlined actions to improve ambulance services, including implementing an improved ambulance performance framework, issuing revised hospital handover guidelines, and improving monitoring and reporting of patient handover delays. They also made the AACE aware of the coroner's concerns.

Action Planned (AI summary) Oldham CCG is co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning Point team to facilitate reflection and agree on actions to improve working relationships. Turning Point conducted a review of GP communication across its substance misuse services and has implemented improvements including changes to prescriber templates, communication frequency, record keeping, and audit processes. These changes have been made across all community substance misuse services. Hopwood House Medical Practice has implemented a DNA policy to discuss patients who do not attend appointments and is considering referring such patients to a Focus Care worker. The practice will also highlight methadone use on patient medication lists.

Action Planned (AI summary) The Trust plans to incorporate awareness of Cushing's Disease into annual training for Core Medical Trainees, using the case as a study, and will discuss the case at local and Salford Royal MDT meetings to disseminate learning.