Inner North London

Action Taken (AI summary) HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and the HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023. Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures to ensure that custodial staff are also able to identify cell-sharing issues.

Action Taken (AI summary) Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs. Point of care testing is fully operational for measuring Streptococcus A and respiratory illness in children; and the Paediatrics service holds weekly meetings to discuss children with complex medical needs.

Action Taken (AI summary) The Office for Product Safety and Standards has engaged with the London Fire Brigade and Tower Hamlets Trading Standards, established a multi-disciplinary safety study, commissioned research into battery safety, and published consumer information on safe e-bike practices.

Action Taken (AI summary) Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's.

Action Taken (AI summary) The London Ambulance Service notes that national JRCALC breech birth guidance has been reviewed and updated with input from the LAS maternity team and senior paramedics. They include updated visuals of breech birth scenarios. The Trust has been alerting the London Ambulance Service NHS Trust (LAS) in respect of any birth plans in place where mothers choose to birth outside of guidance so that they are aware of these cases and the plans for emergency management. The Trust has been working collaboratively with the LAS, and the North East London Local Maternity and Neonatal System (LMNS) to formulate a separate standard operating procedure and guidance for cases where the birth is imminent as there is currently no national guidance on this.

Action Taken (AI summary) The Trust will ensure that all ward staff are aware of service user’s leave status and clinical decisions regarding leave, and is investing £800,000 for Safer Staffing and reviewing recruitment strategy and processes.

Action Taken (AI summary) The Trust has reviewed procedures, met with managers, and is implementing a training programme for Neighbourhood Teams to highlight clinical risk when triaging incoming referrals, which started in March 2023 and runs monthly for 6 months. WWNT members will be required to attend the next Coroner’s Training provided by the Trust’s Legal Affairs Team.

Action Taken (AI summary) Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. The Trust enhanced communication lines, set up monthly review meetings with the hospital, shared learning with staff to escalate safeguarding concerns, and strengthened discharge planning processes. Progress will be reviewed at divisional quality forums, and changes will be embedded in operational procedures by March 31, 2023. Central London Community Healthcare NHS Trust has enhanced communication with University College Hospital NHS Trust by setting up a specific phone number and time for discussing hospital discharges, and set up monthly review meetings. Learning from the incident has been shared with staff, and safeguarding concerns will automatically trigger an internal escalation to the safeguarding team. They have also strengthened discharge planning processes. Westminster City Council has worked with partner agencies to review integrated discharge, and multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care. UCLH has reviewed and improved local processes and education for staff to prevent further poor outcomes for patients. Pressure ulcer training for therapists has commenced, with completion planned by the end of June 2023 and they have agreed to meet monthly as a newly formed partnership to review progress against the actions, share learning and collaborate on improvements. The Trust reviewed and improved local processes and education for staff, strengthened collaboration with community partners, and formed a monthly partnership to review progress, share learning, and collaborate on improvements to enhance the quality and safety of hospital discharge processes and care outside of the hospital.

Action Taken (AI summary) Whittington Health NHS Trust has provided feedback to the nurse who did not escalate the melaena and booked them on a course covering the deteriorating patient, with further training being put in place. The reviewing doctor was given direct feedback and learning regarding anti-coagulation therapy. The 72-hour report was sent to Dr on 4 December 2022 by email – in the week prior to the inquest.

Action Taken (AI summary) KCC has advised staff to immediately inform young adults if their Personal Advisor is on long-term sick leave and provide contact details for the Team Manager and Duty service. The Team Manager will ensure staff add a voice message and out-of-office reply with alternate contacts when on longer-term leave.

Action Taken (AI summary) The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on duty. The team has also been reminded of record-keeping obligations.

Action Taken (AI summary) Following the incident, The Highgate Care Home investigated and revisited the investigation, and introduced measures including using smaller cutlery, ensuring residents are sitting upright whilst eating, reviewing menus with Speech and Language Therapists, and reviewing choking training.