Staffordshire and Stoke on Trent

Action Planned (AI summary) NHS England has published the Maternal Care Bundle (MCB) in January 2026, which includes a national mandate for implementing the Maternity Early Warning Score (MEWS) across all settings by March 2027, and has circulated draft MEWS specifications to digital suppliers. The Trust has established an operational group and plans to roll out a paper-based Maternity Early Warning Score (MEWS) process across the organisation by March 2027, supported by a robust training programme, and will also explore developing an in-house digital solution.

Action Planned (AI summary) NHS England has shared draft guidance with systems, the Personalised Care Framework. North Staffordshire Combined Healthcare NHS Trust has implemented a process to contact patients awaiting Standard Assessment Framework assessments, requires key workers to have confirmed appointment dates before allocation, and clarified transition timescales. North Staffordshire Combined Healthcare NHS Trust is implementing a mandatory electronic alert system for Community Psychiatric Nurses when a service user is newly allocated or has not received an appointment within a specified timeframe, and is also transitioning to co-produced care planning and move away from Care Programme Approach (CPA).

Action Planned (AI summary) NHS England will ensure emphasis on escalation of deteriorating patients with skin and soft-tissue infections during a revisit of statutory and mandatory training for infection and prevention control this year. The Trust is implementing an Electronic Prescribing and Medicines Administration (EPMA) system across both sites, which will provide a record of medication activity. In the interim, a Patient Safety Learning Alert has been developed, requiring staff to document reasons for drug omissions.

Action Planned (AI summary) NHS England reports that the hospital's Patient Safety Incident Investigation (PSII) focused on the issue of failure to manage a deteriorating patient, alongside exploration of the current model of care for medical patients within the ED. Actions taken to mitigate this risk occurring in the future have included developing a new ED clerking proforma, implementing a 'board rounds' process in the ED and agreeing a process for medical staffing of resus. Royal Stoke University Hospital details the circumstances of the death and the concerns raised. It states that it will reinstate a 'named nurse' model within resus from early April 2025, after trialling it previously and finding a 'team approach' better, it has reviewed this decision. The named nurse model will then be audited/monitored via internal review processes.

Action Planned (AI summary) The Trust is drafting a business case for NHS funding for a new EPR across the whole Integrated Care System (ICS), with deployment expected to take 18-24 months once funding is secured.

Action Planned (AI summary) NHS England has set up the Frontline Digitisation Programme (FLD) in 2021 to support NHS Trusts in acquiring modern Electronic Patient Records (EPR) systems and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness. UHDB is working with MPFT to arrange access to Meditech V6 for current short-term bank staff in the Liaison Psychiatry team who do not already have access and is developing a written standard operating procedure for both organisations. MPFT has provided a list of bank staff to UHDB to allow access to patient notes and has developed a joint Standard Operating Procedure for referrals to Liaison Psychiatry and Crisis Resolution teams.

Action Planned (AI summary) Staffordshire Moorlands District Council will replace the speed bumps closest to the incident location with a larger, flat-topped speed bump, painted as a zebra crossing and will investigate additional signage in the interim.

Action Planned (AI summary) Staffordshire County Council is considering cutting back vegetation, installing additional road signs and markings, installing a gate/barrier at the footway, and a possible speed limit reduction to mitigate pedestrian incidents on Eastern Way. They will prioritise solutions alongside their annual road safety programme.

Action Planned (AI summary) Stoke-on-Trent City Council outlines existing duties to provide advice and accommodation, and says it will continue working with health and social care to support individuals released from prison to access GP and mental health services. They suggest the coroner may wish to make a separate report to Central Government on funding for accommodation.

Action Planned (AI summary) MPFT is rolling out a three-year suicide prevention plan, including suicide awareness training, safety planning, family engagement, and real-time suicide surveillance and learning from deaths process.