Norfolk

Action Planned (AI summary) The Trust has revised its SI action plan to include checking the bypass tube at dressing changes, making the reasons for using such tubes prominent on the patient record, and informing nursing staff of the risks associated with such tubes. Longer term, a single patient record system is planned for the region, with interim measures to scan patient records onto an electronic document management system.

Action Planned (AI summary) The Trust is reviewing its recruitment process for doctors to ensure appropriate training and induction, with changes to be implemented by the end of September 2020. The trust also describes existing processes for assessing locum doctors, offering substantive contracts after frequent employment, and encouraging staff to raise concerns. Dr. referred himself to the General Medical Council following the inquest. He has also been proactive in his efforts to improve his knowledge and partake in training for obstetric emergencies including completing the K2 Training Program.

Action Planned (AI summary) The DVSA will add two questions to the driving theory test for new LGV drivers regarding class VI (cyclops) mirrors, planned for the next reprint in autumn 2020. They will also promote Safe Urban Driving/VRU awareness courses and highlight mirror adjustment on social media.

Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has developed a process for joint working between teams for complex cases, implemented a risk assessment process for transfers, and is planning a multi-agency meeting to plan a learning event, following recommendations from a review. The Queen Elizabeth Hospital reports that a multi-disciplinary meeting has been held and a learning event is planned for February 2020, with the West Norfolk CCG taking the lead on organisation. Norfolk County Council commissioned a Serious Case Review with findings and recommendations and a learning event has taken place on 7th November 2019. A further event will take place in early February 2020. The CCG is organizing a multi-disciplinary learning event for NSFT, QEH, NCC, and EEAST staff to address concerns raised in the PFD, with an external facilitator identified and a date in mid-February 2020 planned. The event will include a pen portrait of the deceased, wishes from their parents, and messages from involved staff.

Action Planned (AI summary) The Trust is delivering a learning session on record keeping and communication, emphasizing preparation ahead of appointments. The Trust is also introducing Patient Participation Leads for each locality, working alongside new Clinical Directors to lead quality and patient experience improvements.

Action Planned (AI summary) Norfolk and Suffolk NHS Trust details actions planned including; instructing all clinical services to review their working practice in respect of record keeping and communication with partner agencies and a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager.

Action Planned (AI summary) The CRHT team is using a national fidelity scale, including a point on therapeutic relationships, to reflect on practices and identify areas for improvement, matching clinicians with individuals where a positive relationship has developed; this scale is being used more widely across the Trust.