Liverpool & Wirral

Action Planned (AI summary) The practice plans to review the case with the staff member involved and is investigating the case formally as part of a Significant Event Analysis. It will share the outputs of this analysis with the coroner if helpful.

Action Planned (AI summary) NHS England states that the Department of Health and Social Care committed to engage with stakeholders to understand how the current legal framework is applied in ED settings and identify solutions to the problems raised. NHS England is tasking local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. The HSSIB notes the concerns raised and states that two investigations have been launched: one exploring the care of patients in mental health crisis in emergency departments (launching October 2025), and another exploring ambulance service response to patients in mental health crisis (launching Spring 2026).

Action Planned (AI summary) NHS England describes actions being taken to improve ambulance response times, including the implementation of the 'four high intensity changes' and workstreams focused on patient flow. The DHSC acknowledges concerns about ambulance response times and delayed discharges, referencing increased funding and planned reforms including a 10-year health plan, but does not provide details of any immediate actions taken.

Action Planned (AI summary) NHS England is working on interoperable medicine standards (IMS) to improve medication information sharing, with projects expected to roll out over the next 2-5 years. They also highlight existing screening processes in prisons.

Action Planned (AI summary) Healthcare staff at HMP Garth have been instructed to review and sign the welfare checklist document upon arrival at the wing to inform clinical decision making, with monthly assurance checks to be completed by the Primary Care Manager. A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS. HMPPS is developing national guidance for managing prisoners under the influence of illicit substances, which is currently in the consultation stage. Once agreed, the guidance will be rolled out via regional and local drug strategy leads, who will also develop local guidance and conduct assurance checks.

Action Planned (AI summary) The Department of Health and Social Care mentioned plans to improve A&E waiting times, reduce ambulance response times, expand mental health services through NHS111, and invest in mental health infrastructure. They are also deploying mental health professionals in 999 call centers and clinical assessment services.

Action Planned (AI summary) NHS England will search reported incidents and undertake a thematic analysis regarding EVD incidents over the last three years to identify any additional cases or emerging themes to inform future work, and plans to reach out to the SBNS. They have also highlighted the existence of local policies and national nursing guidance. They seek further information from the coroner regarding a prior escalation of concerns. The SBNS asks its members to review or develop a Standard Operating Procedure (SOP) for EVD use, including an escalation plan for blocked EVDs, and offers to share a relevant SOP from Plymouth.

Action Planned (AI summary) NHS England is migrating users to the National Care Records Service (NCRS), and expects a final toolkit from the National Overprescribing Review to be published in May 2024. Liverpool University Hospitals NHS Foundation Trust is also making completion of the ‘changes to Medication’ part of Discharge Summary documentation compulsory and ensuring that the indication for long-term steroid treatment is included in drug initiation, clerking documentation, discharge letters, medicines reconciliation and primary care records.

Action Planned (AI summary) DfT is launching a national seat belt campaign in March 2024 targeting young men. DfE will share education materials on seat belt compliance with education settings, including DfT’s updated guidance on seat belt compliance. DfE also proposes to make a small amendment to the existing statutory guidance on home-to-school travel.