South Wales Central

Noted (AI summary) The Welsh Government will discuss the incident at the all Wales Serious Incidents Group in October to improve learning and develop/disseminate further guidance across professional groups. They will also keep the case under ongoing review. The University Health Board has implemented a safe system of work for recording items stored in patient PODS, disseminated risk management policies via ward meetings with staff sign-off, and is developing a standard list of documents for disclosure at inquest. NHS Improvement supported the MHRA by searching the National Reporting and Learning System, which reinforced the importance of annual eye screening for patients on long-term Hydroxychloroquine. They stand ready to support the MHRA in ensuring any future changes to monitoring reach healthcare professionals. The MHRA acknowledged the concerns and requested further information regarding the case to determine if regulatory action is required, including observed drug concentrations, symptoms of overdose, concomitant medications, post-mortem sample details, and renal/liver function test results. NHS England is working to ensure that by 2020/21, 280,000 more people with serious mental illness have their physical health needs met. NHS Improvement issued an Estates and Facilities Alert on 'Assessment of ligature points' on 19 September 2018.

Noted (AI summary) NHS Wales Shared Services Partnership Legal and Risk Services outlines its role in advising and supporting health bodies in Wales regarding legal issues, clinical negligence claims, and risk management. They conduct reviews and provide training but do not have the authority to implement service changes. The Welsh Ambulance Services NHS Trust details existing training and monitoring systems for call takers, a review of recent call taker errors, and the intended use of Optima Predict software for demand prediction. They also highlight collaborative work with Cwm Taf University Health Board to reduce ambulance conveyance to emergency units.

Noted (AI summary) Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and primary healthcare, and will discuss collaboration with CSSIW regarding communication between health services and care homes. Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients registering from nursing/care homes; they will audit the process in 6 months. Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the GP, and a specific proforma completed on discharge for patients from care homes; they investigated and addressed an incorrectly addressed discharge summary, noting improvements in access to the Welsh Clinical Portal. CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers relevant elements of care, and is satisfied that no additional policy change is required.

Noted (AI summary) CSSIW cannot impose a blanket ban on care workers assisting service users to smoke, but will issue general guidance to care providers on assessing and mitigating health and fire risks associated with smoking, and exploring alternatives. CQC acknowledges the concerns, notes the service falls under CSSIW jurisdiction, and states their current inspection process covers governance systems, supervision, and accident/incident reviews, but does not support a blanket prohibition on assisting with smoking, preferring a case-by-case risk assessment.