Manchester South

Action Planned (AI summary) The Trust has implemented daily audits for PEWS and sepsis, devised individual action plans, and is using the Patient Safety Incident Response Framework (PSIRF) which has greater emphasis on engaging with those affected by incidents. The Department of Health and Social Care outlines existing programmes to improve digital information sharing in the NHS, including investment in Electronic Patient Records and the planned Single Patient Record.

Action Planned (AI summary) NHS GM will produce an advice briefing for GPs and practices to be distributed through primary care networks, reminding them of responsibilities around mental health patients, mode of appointments, family involvement, and sharing information, including a decision-making tree flowchart.

Action Planned (AI summary) NHS England are featuring the case of Jess Brady in the 2024 NHSE Primary Care Patient Safety Strategy to raise awareness of the need to ‘rethink’ when symptoms remain persistent or unexplained after multiple presentations. NHS England is looking to improve paediatric expertise in the community by supporting local systems to implement neighbourhood multidisciplinary teams for children and young people.

Action Planned (AI summary) MFT has held discussions with GMMH to improve escalation processes for patients whose discharge is being organised by the CMHT. GMMH is in the process of appointing a new Manager for Community Flow and a clearer escalation pathway has been developed between GMMH and MFT. GMMH and MFT have agreed to internally review Ms. Anderson’s patient journey through a Learning Multi-Disciplinary Team Meeting. GMMH will move to a more proactive approach to discharge and will review all admissions of CMHT patients ensuring discharge planning is considered from admission. Inquiries between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record and will be included in the Trust wide Standard Operating Procedure for MHLT’s, plan to be in operation across all MHLT’s by 1st September 2025. An escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3 which prescribes actions and timescales at each level to ensure all options have been considered.

Action Planned (AI summary) Flixton Road Medical Centre details changes made including; reviewing and updating prescribing protocols, implementing mandatory risk-benefit discussions for new or escalated high-level opioid prescriptions, providing staff training in opioid safety and polypharmacy, and conducting regular audits. They have also modified the EMIS clinical system to prompt prescribers at key decision points. NHS GM outlines planned actions including increased use of the SMASH dashboard, pharmacy reviews of patients flagged by the SMASH opioid indicator, development of standards for primary care review of patients discharged on opioids, providing data to GP practices regarding opioid prescribing, increasing awareness of local services and exploring multidisciplinary team review of complex patients on high dose opioids in primary care.

Action Planned (AI summary) NHS Greater Manchester Integrated Care is developing a comprehensive plan to improve access to psychological therapies, with key areas including Workforce Expansion, Enhanced Commissioning Models, and Enhanced Community Crisis Support, including out-of-hours community support, a 24/7 mental health crisis line, and digital support commissioned from Kooth and Qwell.

Action Planned (AI summary) The RCPCH will share information and suggestions for local improvement from the report with its members via its patient safety portal, and the anonymised information will be shared for discussion with the RCPCH Clinical Quality in Practice Committee to identify further actions.

Action Planned (AI summary) Circle Health Group plans to introduce a full Electronic Patient Record, including expansion of an electronic patient observation system into ward-based settings, after completing planned foundation steps. They have introduced digitised systems for consent and pathology/imaging requests and are piloting an electronic pre-operative assessment system.

Action Planned (AI summary) HMPPS has finalised Barricade Guidance, which will be issued to all approved premises staff on 1st August 2025, with staff required to acknowledge receipt by the end of September 2025. A new digital referral process is in place to pull information from prison and probation systems, and Oasys is used by Probation Practitioners to assess risk.

Action Planned (AI summary) The Ministry is working to deliver the Renters (Reform) Bill which will abolish section 21 evictions, is increasing funding for homelessness services and is chairing an Inter-Ministerial Group focused on developing a long-term strategy to get back on track to ending homelessness. It is also delivering 1.5 million new homes and administering the Local Authority Housing Fund.

Action Planned (AI summary) National Highways will repair the boundary fence at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure. They are also in discussion to establish if it is feasible to maintain a more remote access to the electrical cabinets and remove the ladder from the retaining wall.

Action Planned (AI summary) NHS England has committed to issue a reminder to clinicians in NHS trusts on the importance of assessing for, and making, reasonable adjustments when supporting autistic people to gain access to health services and there is liaison ongoing with Disability Stockport in relation to a future Masterclass.