West Yorkshire (Eastern)

Noted (AI summary) The Trust is providing additional 'fit testing' for PPE outside of usual provision and plans to standardise 'bank notes' on shifts in high risk areas specifying the need for fit testing, with audits to check implementation. They have also advised high risk staff to contact Reed to check the status of wards, and carry their risk assessments. Reed Specialist Recruitment states they have complied with their contractual obligations and notified relevant authorities (EAS, CCS, CQC). They suggest the report be re-addressed to ID Medical, the direct supplier of the worker in question. The Employment Agency Standards (EAS) Inspectorate explains its role in enforcing regulations for employment agencies, outlining the checks and authorisations required to ensure the suitability of work-seekers, including healthcare workers.

Noted (AI summary) BAM Nuttall was not involved in the design of the weir installation but will share the Coroner’s Report to Prevent Future Deaths with any designers of weirs in future projects where BAM Nuttall is acting as Principal Contractor. They are committed to the ongoing training of its workforce and the development of ever safer systems of work. BMM JV was not involved in construction or site operations or in the weir design, but will ensure the Report is shared with other designers in future weir projects.

Noted (AI summary) The Department of Health and Social Care is awaiting research on the Brazilian Butt Lift procedure. They will be updating existing guidance about surgical fat transfer procedures to reference the Brazilian Butt Lift by March 2020. The operator of Elite Aftercare confirms the business has ceased trading since the conclusion of the inquest. The GMC acknowledges the concerns and shares information about their role in regulating doctors and setting standards. They note the BAAPS moratorium and discuss credentialing for cosmetic surgery, but state that they do not have the legal authority to make any postgraduate training mandatory.

Noted (AI summary) The University of Birmingham offers condolences and provides background information on its commitment to clinical trials, then addresses specific questions raised by the coroner regarding the medical details of the case, without outlining any actions to be taken.

Noted (AI summary) The Trust acknowledges the coroner's concerns regarding radiology reporting turnaround times but states that there are no national standards. The Trust prioritizes resources to acute, clinically urgent, and cancer pathways, and routine outpatient work may wait longer.

Noted (AI summary) The Trust describes its processes for safe discharge of elderly patients, including defining frailty, use of ACE units, care home liaison, and gathering patient feedback, but doesn't outline specific changes made in response to the report.

Noted (AI summary) HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained staff sufficient based on a first aid risk assessment, referring to PSI 29/2015.

Noted (AI summary) The Royal College of Obstetricians & Gynaecologists acknowledges the concerns regarding CTG training. They note CTG training is part of the current curriculum and offer support for further proposal.

Noted (AI summary) The RCOG acknowledges the concerns and explains that CTG training is already part of the curriculum. They highlight existing e-learning resources and suggest a new proposal could be trialled at the RCOG. The RCM outlines the role of midwives and their responsibilities according to NMC guidelines. They reference existing resources and studies related to CTG interpretation.

Noted (AI summary) The Royal College of Midwives agrees with the coroner's recommendations to retain and safely store placentas for babies compromised in labour. They provide information regarding current practice, disposal and reasons to store placenta within the NHS. York Teaching Hospital is instituting a standard operating procedure in respect to retention of placenta following childbirth by September 2016. They have already established that all placentas are routinely inspected at all deliveries, and that all placentas from stillborn infants or intra partum deaths are sent for detailed histopathology examination.