Inner North London

Action Taken (AI summary) The Trust acknowledged failures in care and has re-trained staff in wound management, including the use of the NEWS2 tool for deteriorating patients. They will also conduct a 3-month action plan to ensure improvements are embedded, including improved communication and escalation procedures with specialist services and GPs.

Action Taken (AI summary) Barts Health NHS Trust is reminding nursing teams about documenting suspected illicit drug use in care plans and handovers. They have reviewed the missing person policy and reminded nursing teams about the risks of making assumptions.

Action Taken (AI summary) The MPS purchased and distributed 100 tablet devices for MSC officers in September 2018 and completed the rollout in November 2018. Local learning was implemented for MSC officers and a CAD operator regarding communication failures.

Action Taken (AI summary) The MHRA considered the adequacy of statutory information for prescribers and patients on the safe use of yellow fever vaccine. They intend to issue a further reminder about the risks of live vaccines in immunocompromised patients via its Drug Safety Update (DSU) bulletin, and has added the report of Mr Griffiths' adverse reaction to Yellow Fever vaccine to the MHRA's Yellow Card database. MASTA has re-evaluated policies and systems, introduced a tick box questionnaire for patients, implemented face-to-face audits at clinics, and observed/documented post-injection advice. They also plan to re-audit clinics of concern and are calling for other Yellow Fever Vaccination Centres to adopt similar preventative measures.

Action Taken (AI summary) • The practice determined that sensitivities to opioid drugs could be recorded in the notes on a case-by-case basis, requiring clinical judgement. • A meeting was held to discuss how the sensitivity to opioids could have been coded appropriately in the GP notes. • A meeting was held with a Royal Free Geriatrician and Compton Lodge Dept Care Home Manager to share Adelaide’s learning and see how this may support recording at the Royal Free and Compton Lodge. • The Trust wrote to the family to seek further information regarding the issues raised during the Inquest. • The patient was cared for throughout her stay in 8 West in what is known as a “high bay”, meaning that staff were present in the bay at all times to supervise the patients. • Water is normally kept on the patients’ bedside tables.

Action Taken (AI summary) The company has reissued instructions that employees should not enter the water to clean pools, updated recruitment processes to determine swimming competency, and removed references to RLSS techniques from club documentation. The company will review and update procedures related to this area by 31 March 2019.

Action Taken (AI summary) The MPS has recommended changes to the Personal Safety Manual, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requiring that where possible the subjects head should be tilted forward; the MPS continues to review and refine existing first aid techniques.

Action Taken (AI summary) The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week, the junior doctor’s induction programme now contains a section around clinical escalation, the numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts, and that this specific case has also been presented through the mortality and morbidity meetings within surgery and medicine and continuing to be provided to all clinical staff.

Action Taken (AI summary) Canary Wharf Group PLC has increased security patrols and implemented a stricter call-out procedure for suspected intruders. They also replaced the torches used by security guards with more powerful flashlights.

Action Taken (AI summary) Addcounsel has changed its system so that clients are discharged entirely to the care of the service deemed more suitable and only case manages clients to whom they are delivering services. Interim measures are in place to ensure the MDT is aware of this change while a formal policy is being agreed and ratified.

Action Taken (AI summary) TfL has fitted additional louvres to two further green figure light aspects on the Pentonville Road crossing. Following the report, 'Look left; Look right' markings have been installed at each of the pedestrian crossings at this junction.