Oxfordshire

Action Taken (AI summary) Thames Valley Police has reviewed their Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons which includes sections on the extent of the search; equipment and resources and potential hazards. The new Premises Search Guidance sets out options for officers when encountering hazards and specifying supervisory escalation requirements.

Action Taken (AI summary) The CRHTT has implemented a designated minute taker for MDT meetings, with minutes recorded on RiO and reviewed and validated by a Band 7 Clinician. The CRHTT is reviewing its medications management process and has developed a flow-chart and an assessment pro-forma to assist with decision making and assessment of efficacy of medications.

Action Taken (AI summary) Oxford University Hospitals NHS Foundation Trust has strengthened mortality review processes by formalising feedback of family concerns and modifying the Serious Judgement Review template to address concerns about scope, focus, or conflicts of interest.

Action Taken (AI summary) The Ministry of Defence has amended its Sharkwatch policy to include written orders for the nominated sober individual, requiring them to keep the group together, ensure safe return, and report deviations, with signed orders retained by the commander; also Part 1 Orders are issued daily containing repeats of all aspects of the Force Protection policy, including alcohol restrictions and actions for duty personnel.

Action Taken (AI summary) The council has reduced speed limits, improved signage, and made speed limit signs more conspicuous with reflective yellow backing boards since the incident. They will also consider additional painted speed limit roundels and propose removing the short third lane by painting hatched lines on it.

Action Taken (AI summary) The OUH has approved 2 additional WTE Rehabilitation Coordinator posts, increasing the number of WTE coordinators to 4 to provide a comprehensive 5 day service. Changes in protocols for the management of pain in chest injuries have also been established.

Action Taken (AI summary) Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points and random spot checks are undertaken to reduce the risk of stockpiling. The Safer Custody Governor is recommending awareness of in-possession medication risks is included in case manager training. HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, with risk assessments informed by healthcare. A safety briefing on in-possession medication has been distributed and ACCT case manager training will cover stockpiling medication. The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger opening an ACCT. The case was reviewed with involved staff, and learning shared.

Action Taken (AI summary) HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record. Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all patient-facing staff.

Action Taken (AI summary) Following the death, guidance was issued to staff that plastic bags must be removed at reception, or staff must accompany the visitor/patient to the room, allow them to remove items, and remove the bag. An independent investigation was carried out and the recommendations have now been completed.