Surrey

Action Planned (AI summary) Holy Cross Hospital has written a policy on ‘Managing a Deteriorating Patient’, including a decision tree for monitoring and escalation, with staff training to follow. They are also implementing an Electronic Patient Record System in the second half of 2022/23.

Action Planned (AI summary) The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.

Action Planned (AI summary) The Department for Education acknowledges the concerns around online content promoting suicide and self-harm, highlights existing guidance for schools, and mentions the upcoming Online Safety Bill which aims to regulate harmful content online. They are also working with the Children’s Commissioner for further recommendations.

Action Planned (AI summary) The Trust will update its CPA policy and Acute Care Services Operational Protocol to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge. The CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust.

Action Planned (AI summary) The Department of Health and Social Care directs readers to the Talk to FRANK website, mentions contact with the Home Office re: powers under the Psychoactive Substances Act 2016, and plans to invest £2.5m in piloting an enhanced RECONNECT service for offenders with complex needs.

Action Planned (AI summary) Epilepsy Action will amend its online information by the end of June 2021 to extend advice about bathroom doors to any door to any confined space. It will also publish an article in its magazine and notify healthcare professional contacts about the issue. The RCPCH will share learning from the death with paediatric specialty groups and OPEN UK to raise awareness of home environment risks for children with epilepsy. They also suggest SUDEP Action could adjust advice on door opening in their resources.

Action Planned (AI summary) The national Safe Working Practice document for Approved Premises is being re-issued on April 30th 2021 and all staff must read the updated SWP and sign a register to confirm this and that they understand the processes. The National Approved Premises Team will also review the EQuiP usage data for approved premises staff to identify any areas where EQuiP usage falls below average and will undertake an awareness raising exercise to reinforce the importance of EQuiP.

Action Planned (AI summary) NHS Digital has reviewed the NHS Pathways script and will work with stakeholders to explore options for improvements. They have committed to reviewing the NHS Pathways training materials to ensure that the importance of encouraging callers to seek support is reinforced.

Action Planned (AI summary) The Department of Health and Social Care highlights ongoing actions to reduce suicide rates through the Suicide Prevention Strategy and Workplan, including reducing access to means online. They are also working with online platforms and chemical sellers to raise awareness of suicide risks and provide support resources.

Action Planned (AI summary) The Trust has reiterated the need to document verbal advice and information, continues to audit medical records, and has embedded documentation of specialist advice in the curriculum for Junior Doctors. The Trust is introducing Electronic Patient Records in December 2021. The GMC will consider the information provided and determine whether any further action is required either through their Outreach or fitness to practise process. Ashford and St. Peters Hospitals emphasizes documentation of specialist advice in training for junior doctors and at Trust events. They will further strengthen documentation by introducing Electronic Patient Records in December 2021. The GMC has opened a provisional enquiry into the actions of one doctor and will obtain clinical records and an independent clinical opinion. No further action will be taken regarding the other doctor. The RCS will consider the coroner's concerns in its 2021 programme of standards and good practice guidance review and development, and shared the correspondence with the British Orthopaedic Association. The BOA will set up a short life working group with haematology colleagues to explore producing guidance on managing complex cases regarding thromboembolism prevention. The RCP has highlighted the need for standards to confirm the accuracy of verbally given advice as a member of PRSB and proposed standards for remote advice documentation based on COVID-19 pandemic learnings. The RCP continues to advocate for integrated electronic record systems.