Inner North London

Noted (AI summary) East London NHS Foundation Trust clarifies that responsibility for environmental risk assessments following the patient's discharge from hospital would lie with the Reablement Team, which falls within the remit of the London Borough of Tower Hamlets. However, they will discuss the case within their regular team meetings. East End Homes states that the smoke alarms were of an appropriate standard, properly installed, maintained, and operated when activated. They believe that residents do not expect domestic alarms to be monitored externally, and they offer general guidance on fire safety. The GP practice will ensure the multi-disciplinary team and Social Services are made aware of concerns raised about the adequacy or safety of a patient's home environment. Clinicians can prompt the Care Navigator or Social Worker at the monthly Integrated Care Multidisciplinary Meeting to ensure that appropriate fire safety checks are implemented.

Noted (AI summary) The Office of Rail and Road (ORR) acknowledges the report but states they do not have the power to take the actions proposed; they recommend the report be directed to Docklands Light Railway Limited (DLR), Keolis Amey Docklands (KAD), and TfL. The ORR says DLR is keeping the topic of obstacle detection under review. TfL and Keolis Amey Docklands will enhance the visibility of platform alarms and continue to work towards a possible trial of CCTV obstacle detection technology; they will also discuss platform CCTV with other light rail operators.

Noted (AI summary) NHS England highlights the existing advice available on the NHS Choices website and the role of Health Visitors in delivering the Healthy Child Programme. PHE aims to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025) through the modernisation of the Healthy Child Programme. The RCN has reviewed and strengthened its guidance about the potential risks of strangulation and suffocation on its clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. This matter has also been brought to the attention of members through Forums and social media platforms.

Noted (AI summary) NHS England will continue to work with HEE, the professional Royal Colleges, and other organizations to stay updated on new guidance and resources for managing severe allergies, and will explore using communication routes or commissioning levers to support their adoption. They also describe their assurance role for CCGs and commissioning of healthcare services. Advanced states they will work with NHS Digital to develop a standard for electronic updating of ambulance systems to inform them when an ambulance has been recalled. They also suggest an independent review of clinical triage systems. NICE notes that the British National Formulary (BNF) and BNF for Children (BNFc) already contain detailed advice on adrenaline auto-injectors, including MHRA/CHM advice from 2017 and 2019. It will consider how best to make clear in CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at all times. Bausch & Lomb distributes trainer pens to allergy clinics and is currently reviewing the design of its trainer pens to incorporate a needle cover shield extension when activated, to more closely replicate the patient experience with the actual pen. NHS Digital details changes made to NHS Pathways following the incident, including improving the Anaphylaxis algorithm, developing an audit framework, and conducting a user satisfaction survey to improve call-handling and call prioritisation. The Winchmore Hill Practice undertook an audit of patients prescribed Emerade to ensure dosage was in accordance with the BNF, reviewed AAI pen doses, and contacted patients with up-to-date advice from the MHRA. The practice has shared learning with the CCG medicine management team and amended the message on scriptswitch; any proposed changes to be made by CCG Pharmacist, will need to be approved by a Senior doctor at the practice. LAS clarifies the division of responsibilities for triage systems, stating that ECPAG and NHS Digital are responsible for setting categories and addressing inconsistencies between systems. LAS will discuss the PFD report at relevant user groups. The Department of Health and Social Care notes several actions, including the FSA working to get emerging trend information and alert local authorities, and working to identify means of access to relevant datasets so they can be included for analysis of food-related cases of anaphylaxis. The Healthcare Safety Investigation Branch (HSIB) will consider the matters of concern in the report and whether these meet its criteria for national investigation when the situation allows. Enfield CCG distributed a Medicines Safety Bulletin on Adrenaline Auto Injectors (AAIs) to GPs and other primary care healthcare professionals on 30th January 2020 and has contacted all GP practices. They are implementing a post-incident review and a report will be completed to ensure all actions identified are implemented to prevent a recurrence, including a review of governance processes and decision-making points.

Noted (AI summary) Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do not support bodycams for nurses due to concerns about patient trust and rapport.