Inner South London

Noted (AI summary) Oxleas NHS Foundation Trust states that Mr. Vukovic was not referred to the Home Treatment Team and explains why. They note that Lifeline would not have been able to provide support and state Mr. Vukovic was discharged to a family who had been involved in his care.

Noted (AI summary) Following the incident, the cardiomyopathy service now ensures that email correspondence with patients is added to the patient's health record. Trust-wide guidelines are being developed regarding email communication with patients. The Department of Health acknowledges the coroner's concerns, references existing GMC guidance on communication, and notes that Barts Health NHS Trust is addressing the issue. They state that concerns about individual clinicians should be raised with the GMC. The Trust is exploring current practice regarding email correspondence between clinicians and patients and will consider local guidance based on NHS England's Accessible Information Standard, pending national guidelines.

Noted (AI summary) The Royal College of Emergency Medicine discussed the case and unanimously concluded that it would not be justifiable or effective to amend the Paediatric Emergency Warning Score to include jaundice.

Noted (AI summary) The MHRA reviewed the SUSAR report and determined that the symptoms were in line with the known safety profile for nivolumab, and no further action is required for participants in nivolumab clinical trials. They also stated that conflict of interest lies outside the remit of MHRA for clinical trials.

Noted (AI summary) London Bridge Hospital implemented several changes including introduction of bedside monitoring and nursing observations policy, the use of SBAR and DOPES handover techniques, and Human Factors Training. They have also added the Cardiac Arrest Record Checklist. The NMC acknowledges the concerns and states that they are currently investigating the matter in accordance with their statutory functions and will provide a further update in due course. The CQC details findings from a 2013 inspection where the hospital met standards for staff training and incident reporting. The hospital introduced a critical care daily safety briefing sheet in November 2015 to address staff sickness, patient problems, admissions/discharges, and specific safety issues.

Noted (AI summary) Virgin Care has implemented a process to ensure colleagues have completed ACCT awareness training and are aware of PSI 1700 upon starting at HMP High Down, with annual refresher training. An auditing process has also been implemented for Fitness for Segregation forms, carried out by Lead Nurses. The Department of Health has brought concerns regarding AMHP training to the attention of the HCPC, which sets criteria and approves training programs. Responsibility for AMHP training is due to become the responsibility of a new regulator; Social Work England, in 2018. The Health Care Professions Council (HCPC) states that its existing criteria for AMHP training programs are appropriate and that individuals completing training have acquired the necessary skills in carrying out mental health assessments. They suggest that issues are best addressed by Local Social Services Authorities through ongoing training. Hampshire County Council and Portsmouth City Council have taken several actions, including reviewing AMHP practices, providing additional training, commissioning audits, and reviewing policies. The HCPC reviewed documentation and closed the case, taking no further action regarding the AMHP's fitness to practice.