Inner North London

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. 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. 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. 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. 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. 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.

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.

Action Taken (AI summary) The Department of Health and Social Care is taking steps to protect users online with the Online Safety Bill, working with stakeholders to remove harmful suicide and self-harm content. They are investing £57 million in suicide prevention through the NHS Long Term Plan, and provided £5.4 million to Voluntary, Community and Social Enterprise organisations.

Action Taken (AI summary) King's College Hospital outlines actions taken and planned following a serious incident investigation, including establishing regular meetings between departments, developing new care pathways, improving access to specialist services, and providing additional training. They also detail how ongoing actions will be monitored.

Action Taken (AI summary) The Department of Health and Social Care highlights existing guidance and resources related to nasogastric tube misplacement, including a patient safety alert and eLearning materials. They also mention the HSIB investigation and the awarding of funding for research on patient safety, including the reduction of never events.

Action Taken (AI summary) Swiss Cottage School has organised Basic Life Support with CPR training for 70 members of staff, timetabled to every class across the school, delivered on 12th and 14th January 2022.

Action Taken (AI summary) East London NHS Foundation Trust has implemented changes to the Crisis Line, including a revised supervision structure, training for call handlers, and improved record-keeping. They have hired four new SI investigators to clear the backlog of reports and agreed to hire an additional solicitor to increase the Legal Affairs Team’s capacity.

Action Taken (AI summary) The agency has outsourced complaints to a clinical team, implemented a policy for reflective statements upon complaint, and can offer immediate additional training; they have also assisted the nurse in self-referring to the NMC.