Inner South London

Action Taken (AI summary) Cambian Group sold Cambian Healthcare Limited in December 2016, so the response was forwarded to Cygnet Healthcare Limited. RadcliffesLeBrasseur, acting for Cambian Adult Services, outlines existing practices including staff tours for familiarity, prioritising internal/bank staff over agency, and an agency nurse induction protocol. The NEWS system has also been introduced at the hospital with staff training.

Action Taken (AI summary) Network Rail demolished and replaced the footbridge at Bostall Manor Way with a new, safer design, including industry standard height railings (1250mm) and acoustic fencing with anti-climb extensions. Old building materials have been removed from the site.

Action Taken (AI summary) The Metropolitan Police Service has rolled out an RT Operators Course since 2011 to selected elements of the uniformed workforce and since July 2014 to all new recruits. They are also planning to implement enhanced driver training, pending release of funds, and are working to ensure officers serving prior to the course introduction may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.

Action Taken (AI summary) Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre.

Action Taken (AI summary) Lewisham Greenwich NHS Trust has implemented actions, including a 'learning from incidents' policy requiring staff to document and handover clear information and a review of handover documentation. They have also used initiatives such as Goldfish Bowl and Whose Shoes? to improve communication between staff and service users.

Action Taken (AI summary) The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly requested an N3 line for direct access to patient records and have purchased laptops for some record access.

Action Taken (AI summary) The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.

Action Taken (AI summary) Greenwich Police enclosed a report detailing their actions, addressing information sharing and risk assessment, as well as their broader response to the serious case review that followed the death. Their response has been reviewed to ensure that measures introduced following the serious case review account for issues raised in the report and are fully embedded in current practice. Bexley Children's Services have implemented lessons learned into social work practice, and a triage system is in place for when looked after children go missing. A risk assessment report is required in preparation for strategy meetings for missing looked after children, and strategy meetings are held within three days of a child going missing. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing.

Action Taken (AI summary) The Trust will refer the case to be included as a reminder in the formal teaching of Foundation doctors and has already shared the incident at departmental governance meetings. ED has revised the transfer checklist for patients being admitted to include results of tests done in ED, and consultants will be notified within 12 hours when their patient discharges themselves from the hospital.