Coventry

Noted (AI summary) • The GP practice has taken actions to monitor potential overuse of inhalers and ensure patients and families are aware of the risks.

Noted (AI summary) The Financial Conduct Authority (FCA) acknowledges the concerns but states that its role is to ensure fair value and good outcomes for customers, not to prevent accidents or mandate specific product features like telematics, which falls outside their remit. The ABI will continue to work with its members to promote telematics for young drivers, advocate for young driver safety within the Road Safety Strategy, collaborate with road safety partners, and campaign to raise awareness of motor insurance frauds. The Department for Transport and DVSA highlight existing resources and campaigns for new drivers, and mention a consultation on introducing a Minimum Learning Period for learner drivers that closes on 11 May. Brake, a road-safety charity, acknowledges the concerns and highlights its campaigning for stronger licensing measures and its delivery of road-safety education, as well as providing support to families bereaved and seriously injured in road crashes. The Chartered Insurance Institute (CII) commits to writing to all general insurance firms with Corporate Chartered status to highlight the report's issues and working with various stakeholders to improve practices related to young drivers, named driver arrangements, and telematics, with guidance to be published by the end of 2026.

Noted (AI summary) The Lift and Escalator Industry Association (LEIA) published a safety notice on their website on behalf of Phoenix Lifting Systems regarding lifting platforms with one-touch platform controls and emailed it to all their members. HSE will raise the matter of platform lifts without hold-to-run controls at the national Local Authority Health and Safety Practitioner Forum and in a technical LA bulletin, and will share the circumstances with CQC and the wider healthcare industry. They are also aware that LEIA has raised the concerns with their relevant committees. LEIA published a further safety notice addressing similar hazards in other lifting platforms from other manufacturers and has made proposals for inclusion of recommendations for the revision of BS 5655-11 to cover legacy lifts with similar hazards. DHSC acknowledges the concerns regarding platform lifts in care settings, but states the responsibility lies with the Health and Safety Executive, who have already responded and are monitoring similar incidents. DHSC shares concerns about the incident but states the matters do not fall within their responsibilities; they have written to the HSE to monitor for similar incidents and review if further action is needed.

Noted (AI summary) NHS England expresses condolences and acknowledges concerns, referring to existing service specifications and the GIRFT program, while noting local arrangements are for the involved providers to respond to, and that they will consider these in due course. UHCW and GEH finalized and shared guidelines for managing acutely unwell kidney transplant renal inpatients, discussed them at the Renal Quality Improvement and Patient Safety meeting, agreed to a Service Level Agreement for UHCW renal team to attend GEH, and have changed internal processes to prioritize interhospital transfers. The UKKA and BTS will share recommendations with kidney care and transplant communities, contact patient associations, and share information with the Royal College of Physicians Patient Safety Committee. George Eliot Hospital received management guidelines from UHCW's Renal Team, shared posters for dissemination on 12 December 2024, and included information on the guidelines in daily briefings from 16-20 December 2024, emailing guidelines to all doctors and consultants on 17 December. UHCW will be the primary specialist transfer centre for all renal patients admitted to peripheral hospitals, regardless of their parent specialist unit, following shared guidelines and SLA. GEH confirms switchboard now has master copy of local specialist centre contact details following UKKA/BTS recommendations.

Noted (AI summary) NHS England expresses condolences and refers to NICE guidance on Apixaban. They highlight that the Regional Chief Pharmacist in the Midlands will review the report and consider learnings for ICBs. They note that the local trust is best placed to address concerns around communication and access to records and that their regional Midlands colleagues have made the ICB aware of the concerns. NICE will further consider the issues raised through their guideline surveillance process to see if an update to the guideline is required and will share the report with Agilio Software for their awareness. The Department acknowledges concerns about national guidance on DOACs and communication between medical staff. They note existing NICE guidance and resources from the British Society for Haematology. CQC will contact the Trust Chief Pharmacist to establish whether the pharmacy was informed and involved in the outcomes of the Trust investigation. The Trust revised its view on the likely cause of the stroke. Bespoke Immediate Life Support sessions have been run across the Cardiology unit, delivered by the Resus Team and Cardiology ACPs. Safety Practice Alerts will be issued reminding staff of clear documentation re stopping/re-starting of DOACs, to be reviewed daily, and the alerts will be incorporated into the Trust's updated Oral Anticoagulant Guideline. The trust will also improve handover processes and ensure the new Electronic Patient Record system highlights information around pausing medication. Audits will be performed in 2026.

Noted (AI summary) Warwickshire Police note the contents of the PFD report but state that the concerns raised are not for the Force, as officers appropriately engaged with Mental Health Services and made referrals throughout. Coventry and Warwickshire Partnership NHS Trust has recommenced internal Risk Assessment Training and is continuing to implement the NICE Guideline on self-harm assessment, management, and prevention. They are also engaging with national bodies to support embedding co-produced standardised approaches to risk-based training. The Department acknowledges the concerns raised and notes that the Coventry and Warwickshire NHS Partnership Trust (CWPT) has addressed the concerns in detail, including updating information packs and recommencing risk assessment training.

Noted (AI summary) NHS England acknowledges the concerns raised and notes the Root Cause Analysis Investigation Report by South Warwickshire University NHS Foundation Trust (SWFT). They also note that SWFT is reviewing referral mechanisms and circulating a safety practice alert and that all PFD reports are discussed by a working group. South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW) jointly reviewed communication and referral processes and completed several actions including a roundtable discussion, confirming a one-contact referral process, circulating a safety practice alert and sharing learning at governance meetings. University Hospitals Coventry and Warwickshire NHS Trust engaged with South Warwickshire University Hospitals (SWUFT) and have agreed an escalation process that provides a direct line of communication 24/7. They will also explore technological options to improve communication and share this with other providers across the System. The Department of Health and Social Care notes that the South Warwickshire University NHS Foundation Trust and the University Hospitals Coventry and Warwickshire NHS Trust have addressed the coroner's concerns. They also note that NHS England has replied and are sighted on the issues raised.