Suffolk

Action Taken (AI summary) • Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework.

Action Taken (AI summary) • The Trust implemented a new electronic patient record system in October 2025. • This system allows internal users to send secure messages to each other on patient records, creating a new line of communication internally. • This has reduced the pressure for response from the medical team for the Medical Assessment Unit by providing an alternative means of communication for internal users.

Action Taken (AI summary) • The Stroke team at WSFT immediately contacted the responsible medical team to clarify the correct TIA referral process with them. • The Trust has updated the TIA referral guideline to improve clarity around the process.

Action Taken (AI summary) The Trust highlights improvements in record keeping and communication, including safety alert learning bulletin emphasizing clear documentation, specific documentation projects to improve fluid balance measurement, thromboprophylaxis and discharge summaries. There are also plans for junior doctors to conduct a VTE treatment audit.

Action Taken (AI summary) Maven Healthcare has implemented mandatory post-incident debriefing, created an organizational lesson learned document, and reviewed policies/procedures for bed rails and falls risk management, and implemented an electronic care planning system. Staff refresher training on falls prevention was completed in January 2025, and electronic care planning was implemented in January 2025 and fully embedded by the end of March 2025.

Action Taken (AI summary) The hospital clarified out-of-hours oncology telephone advice service availability and is implementing improved handover protocols, including a new electronic discharge summary to be piloted. The ED Governance Lead confirmed discharge letters are available to ED clinicians and are referenced to guide clinical decision making.

Action Taken (AI summary) DHSC references existing GPhC guidance regarding remote consultations and verifying information to support prescribing decisions, noting that the GPhC is strengthening its guidance and expectations for pharmacy professionals providing remote services. The 8,500 new mental health workers we will recruit will be trained to support people at risk to reduce the lives lost to suicide.

Action Taken (AI summary) The Trust is starting 3 monthly ERCP Multi-Disciplinary Team meetings to discuss all cases and complications. A cross-site SOP has been drafted and approved entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant”. The Trust is also implementing changes to ensure a named Consultant is allocated to patients.

Action Taken (AI summary) WSFT have disseminated an updated Triage Risk Assessment form to all ED staff on 13th December 2024 and provided Mental Health Awareness Training to ED staff on 16th December 2024; the ICB is currently updating the Suffolk and North East Essex Health and Social Care Protocol for the Support of Children and Young People in Crisis.

Action Taken (AI summary) Norfolk and Suffolk NHS has produced a guidance document jointly with Suffolk County Council to foster better communication between crisis teams and AMHP staff prior to Mental Health Act Assessments, clarifying referral processes. Suffolk County Council and NSFT have jointly developed an information guide for AMHPs on referral criteria and processes for Crisis Resolution and Home Treatment Teams, which has been shared with all AMHPs in Suffolk. Norfolk and Suffolk NHS Trust has worked jointly with Suffolk County Council to confirm a guidance protocol to foster better communications and understanding between the AMHP staff and crisis team, emphasising the need for discussion and communication prior to Mental Health Act assessments.