Inner North London

Action Planned (AI summary) Barchester Healthcare completed themed supervisions with staff, supported by clinical leads, covering RESTORE2 and managing resident deterioration. They also provided staff with 'Clinical Shots' guidance and are reviewing the Appropriate Admission Policy, with a workshop planned for General Managers. NICE will amend its guideline NG89 to recommend VTE and bleeding risk assessment after a decision to admit to hospital, or after 12 hours in ED, or by the first consultant review, whichever is sooner. Recommendations on pharmacological VTE prophylaxis will also be amended to state it should be started as soon as possible and within 14 hours of the decision to admit, rather than within 14 hours of admission.

Action Planned (AI summary) The Riverside Group plans to update its policies and procedures by September 2025 to improve communication and escalation processes when staff have concerns about a resident's welfare, particularly regarding medication and residents on Section 17 leave.

Action Planned (AI summary) OPSS is working with the MHRA to ensure stakeholders involved in the supply of walking sticks are made aware of the incident and requested to review their risk assessments through contact with the British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers.

Action Planned (AI summary) The MHRA will share details of the report with the manufacturer for post-market surveillance and work with the trust to resolve training issues. They will also engage with NHS England to determine if similar cases have been reported and ensure appropriate training is in place.

Action Planned (AI summary) Transport for London (TfL) will trial new technologies this financial year to identify customers on the track, starting with the Docklands Light Railway, Central line, and Piccadilly line, and continue to focus on recommendations from the Formal Investigation into the incident. TfL will implement measures to ensure customer safety information relating to risks associated with intoxication is available at all times.

Action Planned (AI summary) The Trust acknowledges the process of initiating Naloxone was not in line with guidance and will share awareness amongst medical teams. They also outline an action plan including safety huddle sessions on accessing Naloxone, increasing Naloxone stock levels, and updating local guidelines on opioid toxicity management.

Action Planned (AI summary) Daryel Care outlines planned actions, including a formal review of internal processes and procedures relating to incident reporting and escalation, and to enhance training in record-keeping practices. They also commit to seeking clarity regarding designated clinical leads and communication procedures in future projects. The Trust will discuss the case at an ICAT governance meeting, share learning at senior Trust governance meetings, add details to the assessment proforma to require family consultation, audit compliance with additional information completion monthly, and conduct mental capacity assessments for patients not engaging with services. Islington Council acknowledges that no medical points were awarded and will explore opportunities to improve interagency working and information sharing through its integrated front door and integrated neighbourhood strategy. They mention they have identified several areas of learning that will be shared across the organisation.

Action Planned (AI summary) The MPS is reviewing its corporate process for s.135 warrants and will incorporate the matters raised in the PFD report and learning identified into this review. HMCTS has reiterated arrangements for applications to magistrates’ courts in London and held a meeting with NHS colleagues to explore concerns, committing to continued communication and partnership working.

Action Planned (AI summary) The MPS corporate process for s.135 warrants is being reviewed, and the PFD report's matters and learning will be incorporated into this review. HMCTS has reiterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. They also arranged a meeting with NHS professionals to explore concerns.

Action Planned (AI summary) The hospital trust will implement several actions including creation of a new process map for radiology bookings, mandatory training for all staff on radiology protocols, updates to the 'new interventional procedures' policy, implementation of peri-operative care pathways, and development of LocSSIPs (Local Safety Standards for Invasive Procedures).

Action Planned (AI summary) The Royal College of Psychiatrists will communicate risks and best practices regarding cross-titration to its members through newsletters and other communications, raise the issue with mental health organizations, and use the PFD to inform their priorities. It also advocates for more research on the use of video technology in observing patients, and has worked with NHS England to publish principles for trusts considering this technology.

Action Planned (AI summary) Unite Students is reviewing procedures for dealing with calls made to the ECC to effectively triage calls received and ensure appropriate questions are asked to understand the seriousness of enquiries. Welfare checks now escalate to the emergency services immediately if staff can't enter a room, and staff are trained in mental health awareness.

Action Planned (AI summary) Fresh Student Living and UAL will ensure data is shared between teams, specifically the Out of Hours team and UAL and the overnight security cover at Fresh, and collaborate on an awareness campaign regarding where to report drug misuse and dealing. A question will be added to the annual student survey asking students if they are aware of where to notify if they believe drug dealing is taking place in their halls of residence. UAL is taking actions to enhance prevention, identification, awareness, support, monitoring, and enforcement regarding drug use in halls of residence, working with key partners and will introduce questions about drug and alcohol use in their Resident Satisfaction Survey.

Action Planned (AI summary) The Department of Health and Social Care amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services, increasing the number of services and professionals able to give out take-home naloxone. NHS England notes that the responsibility for commissioning drug dependency services rests with local authorities and that the DHSC is the more appropriate organisation to respond. It also mentions that community pharmacies can now supply naloxone and that North Central London ICB will work with Camden Better Lives to highlight good practice for giving training on how it is administered.