North Yorkshire and York

Action Planned (AI summary) YAS will send a clinical alert reinforcing that known high-impact risks, such as swallowing or choking risk, should be explicitly raised at handover where they are clinically active or present a foreseeable risk of harm. Learning from this case will be shared through clinical forums and with system partners. The hospital implemented an immediate action ensuring patients in the Emergency Department are not given food without the oversight of a registered nurse. The Trust has a Standard Operating Procedure (SOP) for Sip Testing in place along with training.

Action Planned (AI summary) Yorkshire Ambulance Service is undertaking a Patient Safety Investigation and will review the initial call, 'fit to sit' decisions, the role of the HALO, and transport to specialist hospital, and is working to introduce equipment risk assessment and reduce number of incidents with mobility equipment.

Action Planned (AI summary) While stating that the existing regulatory framework is proportionate, the Department for Transport has asked officials to consider further options to prevent similar occurrences in the future regarding the safety of occupants of motor caravans.

Action Planned (AI summary) While stating that the existing regulatory framework is proportionate, the Department for Transport has asked officials to consider further options to prevent similar occurrences in the future regarding the safety of occupants of motor caravans.

Action Planned (AI summary) The Trust will update its out-of-date clinical record-keeping guidance and share it with all clinical staff. A patient safety briefing will be drafted and sent to all staff and the case will be presented at a Surgical Clinical Governance meeting. The Trust has implemented an electronic discharge summary, and staff have been reminded of the importance of detailed record-keeping. Referral pathways have been reviewed, and discussions have taken place with surgical teams in York to improve communication and collaboration.

Action Planned (AI summary) The Trust has begun to examine the records of 134 patients with both an Autism marker and a diagnosis of EUPD, to understand the rationale and validity of the diagnoses, how it has been shared, and whether it has been withdrawn, with engagement from clinical teams. The Trust has consulted patients, carers, staff, and external partners to co-create a more inclusive and collaborative service, appointed 2 Lived Experience Directors to the executive team, is expanding peer support worker numbers, and adopting nationally recommended changes to care planning using the DIALOG model. The CCG/ICB is working on a series of learning events with TEWV and service users and is considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice. NHS England highlights several initiatives including funding to improve autism diagnostic pathways, work to reduce restrictive practice and seclusion, C(E)TRs for autism diagnosis removal, and development of a sensory assessment tool and resource pack for health Trusts and Integrated Care Systems (ICSs). Registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role, from 1 July 2022. NHS England is investing £1.5 million into the development and trialling of autism training for staff working in adult inpatient mental health settings by March 2023.

Action Planned (AI summary) NYCC has requested ICES to provide instruction leaflets for equipment and will include a dedicated module with examples and scenarios for completing moving and handling risk assessments and plans in future training for new or existing OTs (February/March 2022); a specialist moving and handling training event for NYCC OTs is scheduled for February and March 2022 and will incorporate a specific focus on instructions as to the purpose of equipment and moving and handling plans. Abbeyfield The Dales Ltd has introduced a new care plan format with images of mobility equipment and updated systems of work, launched a service delivery audit to check care delivery against the care plan, and plans to implement a new equipment process in January 2022 to ensure staff competency with new equipment.

Action Planned (AI summary) North Yorkshire County Council will give further consideration to installing non-prescribed signs at the A59/Broughton Hall junction, despite concerns about accountability. Improvements to signing and road markings will be introduced at the nearby A59/Gargrave Road junction.

Action Planned (AI summary) The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop the CCG website to promote mental health and suicide prevention. It also offers the family a Serious Incident Review. A full action plan is attached with a six-month timescale.

Action Planned (AI summary) The General Pharmaceutical Council acknowledges the concerns and states they are considering publishing an anonymised summary of the case in their newsletter 'Regulate'. It highlights existing guidance and standards, including the importance of patient safety and a two-person check in dispensing, and also emphasizes its work with the MHRA and NHS England to improve adverse incident reporting. NHS England describes actions underway to improve medication safety, including publishing a new Patient Safety Alert on medication errors in March 2014. It also mentions a review of community pharmacy incident data to prepare a Patient Safety Alert, that would better describe risks arising from dispensing medicines, and safer practices including better use of technology and checking systems. The Royal Pharmaceutical Society acknowledges the concerns and says it could raise awareness and encourage use of 'read-back' as one technique amongst others to reduce errors in the guidance that they produce. They also indicate they can raise awareness of additional checks within guidance that they produce. The Department of Health describes actions taken to address concerns around dispensing errors, including the MHRA working with NHS England to simplify medication error reporting. An integrated reporting route has been introduced to share reports, and a National Medication Safety Network is being established to discuss safety issues and improve the safe use of medicines.