Nottingham and Nottinghamshire

Action Planned (AI summary) Nottinghamshire Healthcare NHS Trust is undertaking a further review of the case and addendum to the report. They are transitioning to the new Patient Safety Improvement Framework.

Action Planned (AI summary) NHS England detailed updates to overdose guidance, implemented in November 2023, to include callers who reach a Category 5 disposition. Additionally, TOXBASE is to be viewed for each overdose/accidental ingestion incident, and the initial clinical review should consider any ongoing suicidal ideation with a specific plan/means. Ofcom acknowledges the concerns and outlines its plans to implement the Online Safety Act, including consulting on draft codes of practice and taking enforcement action against non-compliant services regarding harmful suicide content. Nottinghamshire Healthcare NHS Foundation Trust stated that care plans and risk assessments are individualised and updated, with monthly audits to ensure compliance. They have also invested in additional self-harm and suicide prevention training and additional training commenced to support staff and suicide awareness. The Department of Health and Social Care references actions taken to address harmful online content such as the Online Safety Act and states that the multi-sector and cross-government suicide prevention strategy for England was published in September 2023.

Action Planned (AI summary) Sodexo states that the MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include ACCT Assessor training and case manager training. When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before. HMPPS issued guidance and a standard template for Early Learning Reviews (ELRs) in 2021, held a workshop with Group Safety Leads (GSLs) in July 2022, and another in April 2024 to offer additional upskilling. They will mandate the early learning review process in PSI 64/2011 and issue a revised standard template and refreshed guidance document.

Action Planned (AI summary) NHS England developed the TB Action Plan for England, 2021-2026 and commissioned a GIRFT review of TB service provision. They also supported professional awareness resources, a TB eLearning resource, and issued a TB service specification. The UKHSA co-developed and co-owns the National TB Action Plan with NHS England. It has developed and delivered a series of webinars on TB available to healthcare professionals, and contributed to the RCN competency framework for TB nurses. NICE will share the report with their guideline surveillance team to check for new evidence on TB contact tracing. They also plan to discuss the report with the UK Health Security Agency.

Action Planned (AI summary) The trust is developing an updated Infoflex system for MDT coordinators, holding regular MDT excellence meetings, and providing monthly updates to Divisional Management Teams. An MDT Oversight Group will be established in February 2024 to review the project status.

Action Planned (AI summary) A review has been conducted and certain improvements have been or are shortly to be made to the system operated by Central England Co-operative Limited, and further discussions with The British Heart Foundation will take place in due course in the interests of a wider positive impact. The Government has provided funding of £1m for a grant scheme to buy life-saving defibrillators for community spaces, which launched in September 2023. All Automatic External Defibrillators (AED’s) granted by the fund must be registered on The Circuit – The British Heart Foundation’s national defibrillator database which is synchronised with the Computer Aided Dispatch systems of the 14 Ambulance Trusts in the UK and holds the location and where required access codes for defibrillators.

Action Planned (AI summary) The Trust will develop joint learning strategies between Stroke, Neurosurgical, and Neuro-Radiology teams, present decompressive surgery cases at quarterly regional stroke meetings, share minutes of speciality meetings, coordinate responses to SJCRs across specialties, and continue discussing complex Mechanical Thrombectomy cases at the Mechanical Thrombectomy steering group.

Action Planned (AI summary) The Trust will extend the Pathology stop period across the board for all placentas and have discussions with the Coroner's office where a death occurs within 96 hours. This approach is considered more achievable than trying to predict which of the 975 NICU admissions each year will die. The clinical team has been reminded to highlight potential placental pathology on request forms. The Director of Midwifery has reminded midwives to examine placentas prior to sending them to pathology. A new proforma has been introduced for BMS to complete at the time of placenta preparation. The Trust will develop a standard procedure to ensure the medical examiner team informs the pathology laboratory of any neonatal death within 48 hours of birth at the earliest opportunity. The Pathology Department will review examination processes after further information is gained regarding placental examination.

Action Planned (AI summary) Nottingham City Council has developed an overarching action plan, governed by the Senior Leadership Team and Principal Social Workers, to address the concerns raised; the plan will be reviewed monthly.