North London

Noted (AI summary) The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to determine the college's next steps. The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal College of Psychiatrists will consider the concerns and determine if more can be done.

Noted (AI summary) Imperial College London's Toxicology Unit acknowledges the difficulties in accurately analyzing and detecting NPSs due to their changing nature, lack of standards and pharmacological data, and states that no action is proposed. Alere Forensics describes its ongoing efforts to improve the analysis and detection of new psychoactive substances (NPS), including developing novel screening techniques, working with universities to obtain reference materials, and providing training to stakeholders. The Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit at the University of Hertfordshire is engaged in research to identify NPS and provide updated clinical guidelines, including using computational models to identify potential compounds before they appear on the market.

Noted (AI summary) The Department of Health acknowledged the concerns and forwarded the report to the Care Quality Commission (CQC), the independent regulator of health and adult social care providers in England.

Noted (AI summary) The Department refers to existing Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on operative vaginal delivery and General Medical Council (GMC) guidance on record keeping, but does not commit to any specific new actions.

Noted (AI summary) The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising and responding to children at risk of deterioration.

Noted (AI summary) The Department of Health acknowledges the concerns and states that adequate guidance already exists for tracheostomy management through the UK National Tracheostomy Safety Project and other resources, with NHS England continuing to work with stakeholders.

Noted (AI summary) The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient safety incidents associated with Clozapine.

Noted (AI summary) The Department of Health acknowledges the concerns about GPs monitoring medication collection for mental health patients, but cites practical and ethical challenges to implementing such a system. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.

Noted (AI summary) The Department of Health acknowledges the concerns about ensuring patients with capacity attend medication reviews, but states there are no plans to extend mental health legislation and refers to the Mental Capacity Act for those lacking capacity.

Noted (AI summary) AMDEA's Technical Manager on Refrigeration together with industry safety specialists prepared a basic proposal for change to the international standard IEC 60335-2-24. This proposal was placed before the BSI committee CPL61 and was accepted as a UK proposal for change at international level in 2014; the UK proposal was accepted by the International Electrotechnical Commission (IEC) meeting in Tokyo. BSI Committees CPL/61 and PEL/33 reviewed the points raised and are submitting a proposal to the International Committee to add a warning about supply cords and portable socket-outlets to relevant appliances, and a new test for non-metallic material covering thermal insulation. The Society explains its role as a professional body for forensic science practitioners, noting that their reports are usually delivered directly to those who engaged them and may be sensitive or confidential. They state that forensic scientists are rarely involved in fire investigations unless they are serious, unexplained or suspicious, and that the fire service and/or police usually investigate. CFOA will engage proactively with DCLG to help develop the future IRS and the ease by which this type of information can be gathered, accessed and disseminated. CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could provide it to TS and manufacturers if they decided to do so. BIS will consider consistency of guidance and sharing of best practice as part of the independent review of consumer product recalls. The potential for a Code of Practice will also be considered as part of the independent review. BIS will continue to support AMDEA's Register my Appliance site.

Noted (AI summary) The Department of Health acknowledges the concerns about the Home Treatment Team's caseload and refers the Coroner to existing national guidance and resources for Crisis Home Treatment Teams. NHS England intends to map this best practice guidance on to the mental health intelligence network, but there is currently no set timeline.

Noted (AI summary) The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings

Noted (AI summary) The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention for future consideration.

Noted (AI summary) The Secretary of State acknowledges the concerns, notes that guidance was already provided to relevant organisations, and refers to GMC guidance on information sharing. They consider that systems to ensure clinical advice is brought to the attention of treating clinicians should be addressed locally by the NHS Trust. The North West London Hospitals NHS Trust has developed and implemented a flagging system for patients under the care of specialist hospitals with specialist clinical requirements, in partnership with Consultant Paediatricians and the IT Department. A standard operating procedure supports the process and the system has been discussed widely within the Paediatric Directorate.

Noted (AI summary) A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week has been approved and an appointment is awaited. The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient outcomes and weekend services. The response emphasizes local organizations' responsibility for delivering high-quality care.

Noted (AI summary) The Department of Health acknowledges concerns about assessing self-harm risk and providing safety advice, referencing existing government action plans, NICE guidance, and GMC guidance on confidentiality and information sharing.