Manchester South

Noted (AI summary) The Department acknowledges the concerns and outlines national initiatives to improve mental health services and suicide prevention, including investments in community mental health care and digital information sharing. It notes local action by the Stockport CCG and offers condolences to the family.

Noted (AI summary) The Clinical Commissioning Group provides information and context regarding the MPDS algorithm, the identification of ineffective breathing, ambulance performance data, and staffing levels within NWAS, without stating planned actions. NHS England will hold a learning event with all ambulance services and triage system providers to share best practice and ensure ambulance services utilise triage systems safely and effectively in identifying ineffective breathing in asthma patients.

Noted (AI summary) The Department of Health and Social Care will include a link to falls and fractures guidance within its Coronavirus (COVID-19): admissions and care of people in care homes guidance. The Department will also seek clarification from Public Health England and NHS England and NHS Improvement regarding adjustments to falls and fractures guidance for self-isolating care home residents. The CQC acknowledges the PFD report and explains its role as a regulator, including inspection methodology and enforcement actions. It notes ongoing monitoring and liaison with the local authority, but does not outline specific actions taken or planned in direct response to the report.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the planning and commissioning of local health services is the responsibility of CCGs. They note that Stockport CCG has responded and that Mastercall has undertaken to conduct a full audit of the ATT service. Stockport CCG has addressed concerns about the ATT service by agreeing that any visit required following initial telephone assessment will be performed by Mastercall, with exceptions only when a GP expresses a preference. The CCG is working with Mastercall and the wider primary care system to remove a 'grey area' in the service criteria.

Noted (AI summary) The GP confirmed that it is now his practice to carry the equipment with him whenever he attends a patient away from the practice and he will now carry the mobile technology with him and will update patient records immediately following consultation/visit. The CQC acknowledges the concerns, outlines its role as a regulator, and states that a review found insufficient evidence of a breach of regulations regarding the care provided to Mr. Taylor. They will continue to monitor the service and liaise with the local authority. The Department expresses condolences and highlights existing guidance and training related to hydration and nutrition in care homes, referencing the Care Certificate and CQC oversight, but doesn't describe any new actions in response to the PFD.

Noted (AI summary) NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve ambulance turnaround times. PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that other concerns raised are outside of PHE's remit and defers to other organisations. CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the next inspection. They also remained in regular contact with the Provider during the Covid 19 pandemic to ensure awareness of guidance and signpost support. Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly webinars for care homes, and have invited local stakeholders to share learning at a quality improvement meeting. The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency services. They have also reviewed wifi capacity.

Noted (AI summary) The DHSC outlines existing guidance, training and resources related to safe sleeping for infants, including collaboration with Public Health England and the Lullaby Trust. It also notes advice given to local authorities during the pandemic regarding prioritizing health visitor services and awaits a report from the Early Years Health Advisor.

Noted (AI summary) Greater Manchester Police has conducted a review into the triage process of district safeguarding teams, is developing a triage training course including guidance on information sharing, and has recruited a Domestic Abuse Coordinator to ensure a consistent approach to MARACs across the force. Greater Manchester Health and Social Care Partnership will present learning from the Serious Case Review to the Greater Manchester Quality Board and share it with commissioners of services for consideration. Trafford Council states it has already made significant improvements to policies and procedures since 2018 and believes the coroner's concerns are directed to central government. The CPS acknowledges differences in the definitions of a serial domestic abuser and explains the role of the prosecutor in relation to reasonable lines of enquiry. The Dept. of Health and Social Care notes the concerns raised, mentions a Serious Case Review and review of its action plan, and states that local authorities are responsible for commissioning health visitor services based on local needs. The Home Office describes national actions to manage perpetrators of abuse including College of Policing guidance, a review of the Domestic Violence Disclosure Scheme (Clare's Law), and the introduction of new Domestic Abuse Protection Orders (DAPOs) with associated training for police.

Noted (AI summary) The Department acknowledges concerns about the impact of COVID-19 restrictions on vulnerable people in hospitals and care homes, and outlines the national guidance and measures in place to manage visiting safely and support care home residents, including testing and updated guidance based on tier restrictions.

Noted (AI summary) Manchester University NHS Foundation Trust provides context on policies and procedures regarding neurosurgical referrals, head injury pathways, and anticoagulation management. They express sorrow for the patient's death and state that clinicians are required to follow these standards.

Noted (AI summary) Stockport Clinical Commissioning Group states that the correct processes and pathways were followed from the point of consultation with the GP through to the ordering of the echocardiogram and referral to specialist cardiology services. Initial investigations were completed prior to referral in a timely manner.