West Yorkshire (Eastern)

Disputed (AI summary) OneMedical Group disputes that their receptionist training or its frequency was inadequate, stating the incident was isolated and existing annual training already emphasizes eliciting patient information. They believe their training frequency is appropriate and audits show this is not a recurring issue. The Royal College of General Practitioners states that since the pandemic, GP practice custom and practice has changed, now requiring detailed information from patients when requesting appointments. This new system involves clinicians as the initial point of consultation and triage, which is in line with the coroner's request for more information gathering. St James's University Hospital has updated its transfer policy, developed a comprehensive transfer checklist, and embedded a formal sepsis pathway. They have also implemented specific pathways for suspected meningitis and various falls prevention measures including education, safety huddles, and yellow socks for at-risk patients. The Department of Health and Social Care notes existing government funding and plans for improving general practice access and refers to actions taken by the relevant Trust, which completed all recommendations by November 2021. It also notes that NICE is updating its meningitis guideline to include those aged 16 and over.

Disputed (AI summary) The Mid Yorkshire Hospitals NHS Trust has already completed four actions identified in an RCA investigation, including scoping improvements for securing tubing circuit connections. They continue to use filters per BTS guidance, and note the manufacturer is addressing all-in-one circuit availability. The MHRA will agree an investigation plan with Philips Respironics, engage with them on standards compliance, and discuss updating guidance with the British Thoracic Society and NICE. They will also continue to assess incoming data and take action as needed. Philips Respironics argues that the AF541 mask design meets standards, is not intended to prevent disconnection, and is contraindicated for life support. They state the facility failed to follow instructions and incorrectly used an unapproved filter, leading to the incident, therefore no action is proposed. The Department of Health and Social Care acknowledges the MHRA's actions, including requesting a final investigation report from Phillips Respironics and discussions with the British Thoracic Society and NICE on updated guidance. It also mentions the Care Quality Commission (CQC) is monitoring the Mid Yorkshire Hospitals NHS Trust action plan.