Suffolk

Noted (AI summary) NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere. CYP staff will be reminded that a referral ought to be made, staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. Norfolk and Waveney ICB states that they have reviewed their Mental Health Individual Funding Request records and have not been able to identify any Individual Funding Request being made to them on behalf of Ms Madden, for Schema-based Cognitive Behavioral Therapy. Suffolk Constabulary notes the concerns raised but states that they conduct their own risk assessments when delivering Claire’s Law disclosures, which would include the wellbeing of the recipient of that disclosure and the delivery was conducted in accordance with policy and appropriate aftercare. The ICB will work with partners to ensure that learning and action is taken forward from this case, and the Trust has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. The Home Office acknowledges receipt of the report and restates commitment but describes no specific actions taken or planned.

Noted (AI summary) NHS England acknowledges the concerns and refers to actions taken by Norfolk and Suffolk NHS Foundation Trust, including a Quality Improvement Programme, re-evaluation of training, a new SOP, and changes to the Patient Safety Screening Form. They also describe the PSIRF and its aims. Following concerns raised, the Trust has added prompts to the patient safety screening form to consider retrieving patient calls for investigation and inquest purposes. Additionally, they have extended their current recording facility in one of their CRHTT areas which went live on 15th May 2024 and have enabled phone lines designated as requiring a recording facility.

Noted (AI summary) The Department acknowledges the concerns about mental health bed capacity and refers to NHS England's work on improving community mental health services and oversight of the relevant Trust, but does not commit to specific actions beyond raising awareness.

Noted (AI summary) NHS England describes actions taken to improve ambulance performance overall and improve urgent and emergency care services, referencing the Delivery Plan for Recovering Urgent and Emergency Care Services. They also cite the national stroke improvement programme and work to improve communications between ambulance teams and PPCI centers. The East of England Ambulance Service describes actions including additional recruitment of frontline clinicians and control environment clinicians, implementation of an Operational Performance and Improvement Plan, and a review of information shared with Coroners. They have also established an Unscheduled Care Coordination Hub within Suffolk. The Department of Health and Social Care acknowledges the concerns and refers to actions taken by NHS England and the East of England Ambulance Service while outlining broader national initiatives to improve urgent and emergency care.

Noted (AI summary) NHS England acknowledges the concerns, explains information sharing systems, refers to GMC guidance, and mentions internal discussions of PFD reports. They also refer to the Trust's response. The Trust investigated the concerns raised. A change has been made to the discharge summary to include a Primary Care Action to 'please only prescribe weekly prescriptions' when appropriate. The Department acknowledges the concerns, refers to the Trust's response, and highlights existing professional standards and NICE guidance on prescribing practices. The practice will add a note to Summary Care Records limiting medication supply after an overdose diagnosis to 48 hours, and will switch patients with multiple overdoses in 3 months to daily prescriptions.

Noted (AI summary) NICE clarifies that it has not published a guideline on managing chickenpox, but it does publish a Clinical Knowledge Summary (CKS) on its website. They have shared the report with Agilio Software, the external company who develop the CKS. The Royal College of Paediatrics and Child Health (RCPCH) will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal. They are engaging with NHS England and the Patient Safety Commissioner on implementing Martha's Rule nationally and support the recommendation for a universal varicella vaccination programme.

Noted (AI summary) NHS England is implementing improvements to the CYMPH inpatient pathway, aiming to reduce out-of-area placements and move towards community-based care; they are also developing a national admission protocol for children and young people with multi-agency partners. The Department of Health and Social Care acknowledges the concerns and notes NHS England's response and approach to reduce reliance on inpatient mental health beds, moving towards community-based care.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and outlines actions being taken by NHS England and EEAST to improve ambulance response times, including increased recruitment, clinical triage of calls, and the establishment of an Unscheduled Care Coordination Hub.

Noted (AI summary) NHS England is working with Integrated Care Systems to streamline pathways for older adults, including people with dementia, and is focused on improving retention and staff attendance through the NHS People Promise; they will also expand community services including more joined-up care for older people living with frailty and improve falls services. The DHSC acknowledges concerns about resourcing pressures in emergency departments and insufficient provision of care, noting that these are being monitored and that local authorities have a duty to shape their care market.

Noted (AI summary) CHEM notes the concerns raised regarding public entry into containers and will welcome suggestions for additional warnings for operators. Biffa is reviewing operating instructions to ensure clarity on the use of viewing windows, reminding customers about using locks effectively, and continuing to develop relationships with charities supporting rough sleepers. Dennis Eagle explains the design intent of the side window on their refuse vehicles, stating it's for viewing the discharge of container contents and not for viewing the floor of the tailgate. BSI consulted experts and will raise the issue of bin locks when the committee next meets to discuss if changes to existing standards are appropriate.

Noted (AI summary) Hellesdon Hospital has implemented a complete ban on plastic bags, improved communication to families and carers, and put safeguards in place to disrupt the passage of restricted items. The Department of Health and Social Care acknowledges the concerns, mentions actions taken by the Norfolk and Suffolk NHS Foundation Trust, points to a safety alert published in 2011, and outlines progress in reducing suicides.

Noted (AI summary) Suffolk County Council Highways has assessed the report and agreed to install a pair of hidden dip signs north of the Wallers Farm access, facing southbound traffic and will now proceed to design suitable locations, leading to the erection of new posts and signs in due course. National Highways states that they are not responsible for the A137 and cannot comment, advising the coroner to contact Suffolk County Council instead.

Noted (AI summary) The Minister acknowledges the concerns and outlines the responsibilities of CQC registered providers regarding staff training and care delivery. It also mentions NHS England support for care homes and the upcoming statutory inquiry into the Government’s response to the Covid-19 pandemic.