West Yorkshire (Eastern)

Noted (AI summary) NICE declines to develop national guidance on propofol for short-term sedation in children on PICUs, stating that local protocols are more appropriate due to varying local prescribing issues. They suggest that NHS England or the Paediatric Critical Care Society could consider suggesting that all PICUs develop local protocols.

Noted (AI summary) Resuscitation Council UK provides context on its neonatal resuscitation courses (NLS, OH-NLS, ARNI) and states that the NLS approach and algorithm adequately address the potential causes of non-response during newborn resuscitation. The Y&H Neonatal ODN has regional guidelines on surfactant administration and provides education sessions, and has written to all neonatal units in their network and other Neonatal ODNs to share these guidelines and draw attention to the Coroner's concerns. BAPM acknowledges concerns about LISA procedures and reversible causes of cardiac arrest, and while stating that universal consultant approval for LISA is not necessary, they plan to send a safety alert to members and stakeholders drawing attention to relevant recommendations in their Frameworks for practice. The Trust updated its risk register to include risks related to service provision, staffing, and protocols, and are working with the ODN and Commissioners. They also detail actions taken in response to the concerns raised, including changes to the SJUH designation and mitigations for risks due to lack of centralisation. RCPCH acknowledges concerns regarding LISA guidelines and reversible causes of cardiac arrest but defers to BAPM and RCUK for specific guidance and actions, noting they expect members to follow Resuscitation Council UK guidance. The Department acknowledges the concerns regarding maternity services at Leeds Teaching Hospitals NHS Trust, particularly staffing levels and the delay in centralizing services due to the New Hospital Programme's revised schedule, but defers to the Trust for specific responses and emphasizes existing duties for Trusts to maintain adequate staffing. This is an exhibit referenced by another response. It is a LISA checklist.

Noted (AI summary) Leeds Community Healthcare NHS Trust outlines actions taken, including a working group to review the Death in Custody procedure, reflective conversations with staff, and inclusion of 'coordination of response' in the investigation process. They are enhancing CPR training and clarifying the contents of the emergency bag. They clarified that the intervention was an intramuscular injection of Naloxone, not an intraosseous needle. West Yorkshire Police clarifies the roles and training of Detention Officers in medical emergencies, emphasizing their responsibility to provide basic life support until a Healthcare Professional arrives and to follow the Healthcare Professional's directions. However, the Chief Constable intends to review contracts, policies and procedures between the Force and Leeds Community Healthcare to ensure clarity on roles in emergencies.

Noted (AI summary) The practice will adopt a protocol to ensure GPs do not treat immediate family members, according to GMC guidelines and current Good Medical Practice guidelines. The GMC acknowledges the coroner's concerns regarding a doctor treating a close relative, referencing their guidance that this should be avoided where possible but is not explicitly forbidden. They state that they will assess if the individual poses any current and ongoing risk.

Noted (AI summary) West Yorkshire Police has implemented changes including a quarterly review by the DCI at Professional Standards, an annual review by the Head of Professional Standards, and quarterly meetings between the senior leadership team at Professional Standards and senior leaders at the IOPC. The IOPC acknowledges the concerns and highlights existing guidance and the ongoing Transformation Programme to improve timeliness, but states that primary responsibility for welfare rests with the officer's force.

Noted (AI summary) The Trust acknowledges the concerns raised and states that postnatal care was carried out within national guidance. They note that postnatal maternity wards are not conducive to rest and recuperation and that most mothers prefer to return home.

Noted (AI summary) NHS England will work towards surfacing inclusion data to patients via their NHS App and will promote the Digital Clinical Safety Strategy. They also state that all reports received are discussed by the Regulation 28 Working Group. EMIS acknowledges the coroner's concerns and states that their EMIS Web system has inbuilt safety principles and complies with NHS specifications. They will continue to review their solutions but believe no further software developments are required. Cegedim plans to consider implementing functionality to take patient age into account when recording weight or height for BMI calculation in future Vision clinical system updates. TPP acknowledges the concerns regarding BMI calculations in GP IT systems but states that the erroneous entry was made on a previous system and that the current system, SystmOne, has validation in place for height and weight measurements. They suggest national-level requirements for BMI validation to ensure a consistent approach. The RCGP will ask the GPITC to discuss the concerns at their next meeting in July 2024 and will ask NHS England to consider coordinating funded clinical safety workshops. They will highlight the importance of accurate data entry through their continuing professional development program for members. The BMA will discuss the concerns at their next Joint GP IT Committee meeting to raise awareness and seek consensus on how systems might evolve. They will also advocate for improvements in NHS IT systems so patients have greater confidence in treatment decisions.

Noted (AI summary) The Trust will review patient safety leaflets in accordance with guidance from professional bodies such as the Royal College of Radiologists and British Society of Interventional Radiology to ensure they are supporting patients with the most contemporary medical advice. The RCR acknowledges the concerns, noting points 1 and 4 are outside their remit. They endorse GMC guidance on consent and state they don't produce patient information leaflets.

Noted (AI summary) Festival Republic implemented improvements for Leeds Festival 2023, including enhanced security at gates, search operations, presence of dogs, visible messaging, and covert operations. They addressed medical facilities concerns by improving the Forward Operating Base, triage processes, ambulance resourcing, and welfare support. They also plan to consider further improvements for the 2024 festival. Leeds City Council, via its Licensing Committee, detailed enhancements made by Festival Republic for the 2023 Leeds Festival, including improved security and stewarding, SIA-accreditation checks on security staff, enhanced staff manuals, daily briefings, and new AIR Hubs. Arrest data analysis suggests Festival Republic's drug security strategy was effective, with increased arrests and drug-related arrests in 2023. Festival Republic provides updated arrest statistics from West Yorkshire Police regarding drug offenses at an event. West Yorkshire Police increased measures to combat drug supply at the 2023 Leeds Festival, including a dedicated intelligence researcher, liaison with other festivals, robust searches at ingress points, increased use of drug dogs, covert operations, and a WYP officer stationed in the Festival Republic Control Room, resulting in more arrests. They will also ensure a dedicated detective inspector attends the hospital with the ill person in future. The Home Office highlights government efforts to tackle illegal drugs through police action, reducing demand, and improving treatment. It notes that organisations wishing to deliver back-of-house drug checking facilities at festivals can apply for a license.

Noted (AI summary) Leeds City Council acknowledges the coroner's concerns regarding a lack of legal powers to access properties for safety works without tenant consent. The council states that granting additional legal powers to landlords is a matter for central government. The Home Office acknowledges the coroner's concerns about fire risks in social housing but explains the existing regulatory framework, including the Regulatory Reform (Fire Safety) Order 2005 and the Housing Health and Safety Rating System. It highlights the role of Fire and Rescue Authorities and the Home Office's Fire Kills campaign.