Norfolk

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.

Action Planned (AI summary) The staff in the clinical area have received support to ensure they understand and use the current escalation system. The Trust will adopt the National Early Warning System (NEWS2) on November 1st 2018, including new documentation, training and escalation procedures.

Action Planned (AI summary) The Trust is engaged in a program to improve record-keeping, including risk assessments and care plans, with active monitoring at all levels. They are also working with business change and training specialists to develop staff use of the Lorenzo electronic patient record system and with system suppliers to improve its performance.

Action Planned (AI summary) The CAA is conducting a review of rules for flights under Instrument Flight Rules (IFR) outside controlled airspace, scheduled for completion by September 30, 2016. They will also renew Safety Notices and update AIP details by March 31, 2016, to provide enhanced information for pilots.

Action Planned (AI summary) • The CAA has instigated a thorough review of the rules applicable to flights performed under Instrument Flight Rules (IFR) outside controlled airspace through our Safety Review Committee. • This review will cover several of the issues raised in relation to this accident as well as the wider context of current and emerging practices and is scheduled to be completed by 30 September 2016. • Before taking off, the pilot of helicopter on private flight must be satisfied of a number of matters including that the flight can safely be made, the aircraft is in way fit for the intended flight