City of Sunderland

Noted (AI summary) Riverview Surgery has implemented a new Standard Operating Protocol (SOP) for prescribing medication to women of childbearing age, which includes stopping contraindicated medication and advising patients if they become pregnant. The frequency of reviews for female patients on ARB medication has been increased to three-monthly. The RCGP outlined its role in setting prescribing standards and mentioned the mandatory Prescribing Assessment introduced in 2019. It suggested exploration with system suppliers regarding alerts for existing repeat prescriptions when a patient becomes pregnant, and highlighted the new Learning From Patient Safety Exercise reporting system.

Noted (AI summary) The Minister will write to Swim England to explore how awareness of the 'Beyond Swim' accreditation scheme and associated guidance can be increased. They will also continue to work with sports bodies to ensure safety is prioritised. HSE acknowledges the concerns, explains that existing regulations (HSWA and MHSWR) apply to open water swimming events, and that relevant guidance is available from other sources. HSE will not be publishing specific guidance at this time but will raise awareness with local authority enforcement officers.

Noted (AI summary) The NPA will raise concerns with the DHSC about Zuclopenthixol dihydrochloride (clopixol) packs and special container status at upcoming meetings, suggesting the DHSC is a more appropriate body for the report. The General Pharmaceutical Council acknowledges the concern and will consider whether to issue communications to pharmacy professionals to raise awareness about exceptions to the rules around quantity to supply for special containers. Lundbeck states it does not classify Zuclopenthixol as requiring special container status, but has queried the NHS Business Authority and provided supportive stability data. The MHRA confirms that the GPhC led on the response to the report, shared on 7 May 2024, and that the response is supported.

Noted (AI summary) The Trust states its investigation didn't identify issues with care provided to Daniel Futers or compliance with Trust policies/procedures, except for missing belongings. The response asserts policy regarding patient leave was followed and is fit for purpose and notes ongoing efforts to improve communication with carers/family.

Noted (AI summary) Cumbria, Northumberland, Tyne and Wear Foundation Trust has implemented several measures to proactively engage families, including integrating family support as a core offer, providing family therapist assessments, and reviewing and implementing systems to ensure carers are offered intervention. The Trust also plans further improvement work in 2022/23 to increase staff time with service users and carers. The Department of Health and Social Care acknowledged concerns about mental health workforce capacity. It noted an increase in the mental health workforce and highlighted ongoing national plans to expand the workforce by an additional 27,000 professionals by 2023/24 through significant investment.

Noted (AI summary) POM EKO explains the safety measures and procedures already in place for their modular steel pontoons, emphasizing the importance of using factory-made binding elements and avoiding unauthorized modifications, and that they have extended the interval between anti-corrosion coating and closure to remove volatile compounds. They also note the legal obligations of employers to ensure workplace safety.

Noted (AI summary) The response acknowledges the death and outlines current NICE guidance on managing large babies and gestational diabetes, noting an ongoing trial on inducing labour for predicted macrosomia.

Noted (AI summary) The Trust states that all staff working with dementia patients have received appropriate training, and policies and guidelines are put into practice with staff receiving information and/or training on their implementation, and audits in place to monitor compliance. The Minister acknowledges the concerns, describes existing training frameworks and personalized care approaches, and mentions the Health and Care Bill's aim to improve integration of health and social care services.

Noted (AI summary) • The company's Clinical Application Specialist (CAS) will be on- site for a total of 4 weeks to provide on-site training and support. • The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors. • The company will also deliver 'Train the Trainer" with individuals to ensure future new starters can be trained following this initial period.