Gwent

Action Taken (AI summary) • A revised escalation and referral protocol has been implemented within the Cardiac Device Clinic. • A mandatory referral trigger is now in place if a device has lost a twofold safety margin, documented in the "Managing the Unwell Patient Standard Operating Procedure". • The Standard Operating Procedure has been shared with all Physiologists and will be presented at the departmental Quality and Safety meeting on the 13th of May.

Action Taken (AI summary) Aneurin Bevan University Health Board has a Standard Operating Pathway (SOP) for the management of surgical patients presenting to preassessment clinic with anaemia or iron deficiency. The cost of IV iron is charged to the relevant clinical area, regardless of patient residence or Health Board boundaries.

Action Taken (AI summary) The Trust has undertaken a review of practice and implemented actions including developing a Standard Operating Procedure (SOP) to ensure standards/guidance are set for dietitians to consider when making clinical decisions regarding telephone review and face to face sessions and an audit of the SOP once implemented. The Health Board has implemented a strengthened governance framework dedicated to nutrition and hydration, including a Strategic Nutrition and Hydration Group, supported by two operational sub-groups and is working with VUHNHST to ensure consistent standards when providing dietetic care.

Action Taken (AI summary) The organisation is reviewing its leave policy and has implemented interim changes at Aderyn, including reminding staff to ensure no reason to stop ground leave, to record issues related to leave, and the Hospital Director will audit carenotes weekly to ensure records are made.

Action Taken (AI summary) Aneurin Bevan University Health Board details its Falls Policy for inpatients, including risk assessments, post-fall reviews, and environmental safety measures. It also describes staffing level audits and processes to manage nurse staffing deficits.

Action Taken (AI summary) Gwent Police confirms national training on Acute Behavioural Disturbance (ABD) has been reviewed and a new learning package introduced from 14 February 2024, incorporated into mandatory Public and Personal Safety Training and First Aid Training. From 3 April 2024, frontline officers will receive bespoke standalone specific ABD training, emphasizing the "Speak Up and Speak Out" principle.

Action Taken (AI summary) The Health Board clarifies its position on delegation of nursing responsibilities to family members. They also report implementation of a digital platform for visibility of staffing levels and dissemination of an 'Educational and Recommendations After Significant Events (ERASE) Poster' to share learning from the case.

Action Taken (AI summary) Monmouthshire County Council confirms that the chevron signs were erected on 22nd March 2023 and that the foliage has been cut.

Action Taken (AI summary) Aneurin Bevan University Health Board is reintroducing training on falls risk assessment and prevention, reviewing the falls risk assessment process, and developing an action plan to capture and monitor actions, and is exploring learning from the use of sensors in care homes.

Action Taken (AI summary) The Richmond Clinic investigated the matter, met with the Health Board, explored communication options between primary and secondary care, and ensured all clinical staff are aware of them. They have explored obstacles to communication in this case and addressed them. The Health Board has established a single point of access Flow Centre for urgent referrals for admission, launched direct access telephone advice lines, and created a directory of "bypass numbers". The Medical Examiner Service is now operating in Gwent and GPs receive a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services.