Norfolk

Action Taken (AI summary) The Night Work policy, incorporating a successful daily notes audit to prevent pre-recording of observations, was uploaded to the QCS system and added to the staff reading list on 01/08/2023. They have also engaged an external compliance company for more thorough inspections and monthly visits to assist with continuous improvement.

Action Taken (AI summary) The Trust updated VTE guidelines with NICE guidance, introduced mandatory e-learning on VTE, rolled out NEWS2, mandated patient monitoring documentation in Tendable© audits, and implemented a Patient Safety Incident Response Plan, identifying VTE as a focus area. They are also working with other trusts on a joint Electronic Patient Record System implementation by 2025.

Action Taken (AI summary) The Department of Health and Social Care highlights the 'Delivery plan for recovering urgent and emergency care services', investments in virtual wards, and the Discharge Fund to improve patient flow and reduce ambulance handover delays. They note improvements in A&E performance and handover times at the relevant hospital.

Action Taken (AI summary) Runwood Homes has implemented changes including a new pre-admission form, staff training on individualised care plans, improved medication management protocols, and monthly care plan audits by the senior team.

Action Taken (AI summary) DAC Beachcroft, on behalf of Lincs Firewood Company, states that the procedures were either already in place at the time of the incident, or have been enhanced since. Training includes task-specific chainsaw maintenance, emergency first aid, and health and safety modules.

Action Taken (AI summary) East of England Ambulance Service has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at hospitals in Norfolk to improve response times for critical patients, and shared a briefing for HM Coroners in relation to hospital handover delays. Spire Norwich Hospital has added wording to patient admission letters to ensure all patients are aware that the hospital does not have an on-site critical care unit, and has agreed a process with East of England Ambulance Service for clinician to clinician discussions regarding inter-provider transfers.

Action Taken (AI summary) East of England Ambulance Service is working with system partners and the Healthcare Safety Investigation Branch (HSIB) to manage call demand, has implemented daily system calls with stakeholders, and has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at a local level in Norfolk. The hospital added wording to admission letters informing patients it does not have an on-site critical care unit. They agreed a process with EEAST for clinician-to-clinician discussions during delayed ambulance responses to share detailed patient information.

Action Taken (AI summary) Norfolk and Suffolk Foundation Trust has implemented a Safety Day training program, created a policy folder with policy summaries, and revised the physical health audit process, along with improved training for staff to complete ECGs and phlebotomy; staff now have bleeps for rapid response.

Action Taken (AI summary) The Queen Elizabeth Hospital King's Lynn reports that the checklist for patients in the Emergency Department has been upgraded to include a specific reference to investigations.

Action Taken (AI summary) The Trust outlines actions taken following the death of Tracy Wood including: review of staffing levels, changes to observation policy, review of access to patient information, review of the SBAR tool, and updates to the PSII report process. They also mention routine uploading of the SBAR tool onto the electronic record.

Action Taken (AI summary) Hellesdon Hospital has updated its discharge policy to include a documented discussion and MDT review prior to discharge, particularly for young people. They are also working with service users to improve communication and engaging in suicide prevention initiatives.

Action Taken (AI summary) Hellesdon Hospital is updating the Trust induction for junior doctors to include physical health training, supported by senior consultants and underpinned by the SBAR framework. They will offer "3 Ps" training to all staff, rolling out "bite-size" training on VTE, and set up a working group for flexible working colleagues to support an education passport for health workers.

Action Taken (AI summary) Hellesdon Hospital has implemented several actions including increasing capacity of the Central Youth Team, developing a locality model, developing a transition service, and recruiting senior nurses and consultant psychologists. They have also added relocation incentives to recruitment adverts and are offering remote working where appropriate.

Action Taken (AI summary) Jeesal Residential Care Services has made changes to its board membership and oversight, including independent verification of reports, commissioning staff and family surveys, and a decision not to run hospital services in the future. They are also reviewing residents' placements and care packages to ensure appropriateness. The Norfolk and Norwich University Hospitals have discussed Mr King's case and raised awareness generally of the importance of obtaining tests when they are needed to inform the management and next stage of a patient's treatment. It was acknowledged by HM Coroner's expert that there was a spectrum of decision making available in this case, with admitting Mr King at one end of the range and sending him home at the other end.

Action Taken (AI summary) Premier Rescue Ambulance Service Ltd. has trained all staff, including drivers, in CPR, with one member of staff now authorized to train others internally. The company has also implemented a policy to no longer transport patients who are not awake and responsive at the start of the journey and requires a qualified medical practitioner confirming a patient's fitness to travel.

Action Taken (AI summary) The Queen Elizabeth Hospital Kings Lynn provided a medical records audit across the Trust's wards. They also have updated falls risk assessments and management plans to include contacting Mental Health Liaison. A review of the QEH guidelines for those on Fresnuis is underway and due by the end of February 2021.

Action Taken (AI summary) SBARD is integrated into the patient handover used by the wards at every handover, with a template document used. EObs has been introduced. The Recognise and Response Team (RRT) has been expanded to provide their services 24/7 and teaches SBARD on all new staff inductions.