Shropshire, Telford and Wrekin

Action Planned (AI summary) The ICB is developing a Safety Improvement Plan, with actions including: a Working Group to review patient counselling and informed consent regarding medications being prescribed in hospital; learning from the case to be used to deliver training to junior doctors; and a new Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis pathway to be developed and published within the Trust. Following an internal investigation, the Trust has established a multi-disciplinary working group to address concerns around patient counselling and informed consent regarding medications prescribed in hospital and is referring patients requiring additional support to the Discharge Medication Service and Structured Medication Review service.

Action Planned (AI summary) The trust states that the coroner's concerns have informed the development of a Health in Justice Suicide Prevention Plan, including a multi-agency Suicide Prevention Forum, and will share the results of an inter-agency review with staff and partners. Completion is expected by September 2024. Following an inter-agency review, the trust is implementing actions including refresher training, improving the ACCT procedure, updating risk assessment documentation, and reviewing procedures for transferring prisoners to establishments with hospital wings. Various completion timescales are provided, ranging to September 2024. HMPPS will present an operational briefing to staff on responsibility for ACCT checks. They have updated Case Co-ordinator processes, and are sharing QA with managers, and meeting with partner agencies to relay responsibilities.

Action Planned (AI summary) MPFT is reviewing the fence structure around the garden on Laurel Ward, with options including a full replacement fence or retrofitting an anti-climb dome; the Trust is also discussing ways to complete searches of the garden at set frequencies, such as bi-monthly, and these will be addressed through the Trust’s Health and Safety Committee for action and monitoring.

Action Planned (AI summary) Midlands Partnership NHS Foundation Trust is redesigning counselling services to reduce waiting times, with completion planned within six months. The Trust is also further developing the Rio system to improve the clarity of electronic patient records, although clinical staff cannot overwrite or delete entries without the system recording it.

Action Planned (AI summary) NPAS will support West Mercia Police in a critical incident debrief and offer opinions on improvements in awareness or training. They will also discuss the matter with the NPAS Independent Assurance Group and the NPAS Local Strategic Board. West Mercia Police has undertaken an extensive programme to raise awareness of vulnerability, piloting a programme in Telford and rolling it out across West Mercia in 2017. They have also provided clear guidance relating to NPAS call out procedures and capability to all officers.

Action Planned (AI summary) Telford & Wrekin Council has compiled a plan of action building upon recommendations made in the Domestic Homicide Review report, and the implementation of the action plan will be formally monitored by the Safeguarding Adults Board. The Adult Safeguarding Policy and Thresholds has been recirculated, domestic abuse leaflets and guidance has been circulated, and an education and training event for Telford & Wrekin GPs and Practice Nurses will be funded and delivered with a focus on safeguarding requirements and domestic abuse. West Mercia Police will provide a reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation to all operational staff. The tactical equality and diversity advisor has recently attended a Dementia Friends workshop to scope the feasibility of additional awareness sessions, and the arrangement of a joint working group will be tasked by the Safer Communities Partnership to the Safeguarding Adults Board.