South Yorkshire East

Noted (AI summary) The Trust acknowledges the concerns raised in the PFD report regarding the death of Mr. Horton, but states that a falls risk assessment was completed and wound care was delivered in accordance with Trust policy. The Trust maintains a skin integrity improvement plan and a discharge action group is in place.

Noted (AI summary) This is a data report from Rotherham NHS Foundation Trust on inpatient falls, including falls rate, bed days, and moderate or above falls, with comparisons to national benchmarks. Rotherham NHS Foundation Trust has assigned falls champions on each ward and healthcare assistants on every shift to ensure lying and standing blood pressures are completed, added a mandatory question to the inpatient discharge summary about falls/VTE/pressure ulcers, and included Datix reporting information in the induction for temporary staff. This is a template document for Rotherham NHS Foundation Trust's Care Group 1 (Medicine) safety huddle log, to be completed three times daily to review patient safety, safeguarding, staff wellbeing, and other key issues. This is a template document for Rotherham NHS Foundation Trust's Care Group 1 Nurse in Charge handover checklist, to be completed at each handover to ensure key information is communicated and actions are taken.

Noted (AI summary) The organisation acknowledges receipt of the letter and clarifies the relationship between National Care Consortium and Pristine Care Group Ltd. The care home has implemented processes and protocols to address identified shortfalls, with auditing duties carried out by the senior management team. A CQC inspector reviewed the protocols and was happy with the improvements.

Noted (AI summary) National Highways expresses sympathy and highlights existing measures to improve safety, including public awareness campaigns and the Smart Motorway Safety Evidence Stocktake and Action Plan. They urge road users to inform themselves about emergency procedures and who to contact.

Noted (AI summary) Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England. Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage starting CPR unless irreversible death is certain. They have shared the response with relevant bodies.