Milton Keynes

Noted (AI summary) Milton Keynes Council states that they adhere to a risk-based approach to highway maintenance, in line with national guidance, and that inspections did not reveal any actionable defect at the location. They will continue to fulfill their statutory obligations as the Highway Authority.

Noted (AI summary) The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024.

Noted (AI summary) NHS England expresses condolences and explains its role as a facilitator for system partners working to deliver recommendations from a Public Health England review on prescribed medicines. It describes national resources and notes actions taken by the BLMK ICB and Hilltop Surgery regarding opiate prescribing audits and medication reviews. The response also mentions a working group that shares learnings from PFD reports. Hilltops Surgery reviewed the case, audited patients on high-dose opioids, ensured 3-monthly reviews for certain patient groups, discussed the case with the Integrated Care Board, and arranged a meeting to review NICE guidelines on safe prescribing. The surgery also implemented face-to-face medication reviews and a call-and-recall system.

Noted (AI summary) The Department for Transport outlined existing GB domestic and working time regulations for drivers of light goods vehicles. They stated that if the driver fell asleep due to inadequate rest, existing regulations would apply, and offered to coordinate with DVSA for an investigation if employer details are provided. NHS Milton Keynes University Hospital NHS Foundation Trust has communicated to all Registered Nurses (RNs) and senior staff via matrons and safety huddles, reiterating the importance of active monitor alarms and staff visibility. Senior nursing teams have also provided initial training on transferring data from monitors to modules, which will be added to medical equipment training.

Noted (AI summary) Milton Keynes University Hospital outlined actions taken, including managing involved individuals, sharing resources, implementing the Association of Anaesthetists Quick Reference Handbook, and standardising monitor configuration across theatres. They are also working to improve teamwork, communication, and safety culture across multidisciplinary teams. The Royal College of Anaesthetists (RCoA), in collaboration with the Association of Anaesthetists and the Difficult Airway Society (DAS), will address issues through a coordinated campaign to disseminate and embed lessons learned into practice, including developing resources for multidisciplinary team training, working with stakeholders to highlight human factors, and spreading key messages through journals, newsletters, social media, and educational events. The Department of Health expresses condolences and notes actions taken by Milton Keynes University Hospital NHS Foundation Trust and the Royal College of Anaesthetists. They highlight national initiatives such as simulation-based training and equipment standards, but describe no specific new actions. They have brought the report to the attention of the CQC and HSIB. The Royal College of Anaesthetists (RCoA), the Association of Anaesthetists and the Difficult Airway Society launched a coordinated campaign including a dedicated webpage, educational talks, articles in members' magazines, and social media promotion to disseminate learning points from the case. They will develop more resources for multidisciplinary team training and maintain work to prevent unrecognised oesophageal intubation through the Safe Anaesthesia Liaison Group.