Inner South London

Action Taken (AI summary) 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. 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. 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 GP now ensures that during consultations with significant problems, they check past reviews and previous consultations. They also check to see if any reviews are outstanding, and either complete them or ask the patient to make an appointment and record this advice within the patient's electronic record.

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.

Action Taken (AI summary) The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also spoken to clinical leads regarding the use of the drug and side effects.

Action Taken (AI summary) The Adventure Company has reviewed its Nepal high altitude treks against Wilderness Medical Society guidelines and implemented changes to reduce some altitude increases, to be fully implemented by the start of the new trekking season in September. They have also removed a manual that referred to finding cost effective solutions.