Wiltshire and Swindon

Action Planned (AI summary) The HSE will work with their communications team to send out a copy of the Wilts & Berks Canal Trust prosecution press release in the main HSE ebulletin series and will consider the coroner's recommendations when they next review the volunteering pages of the guidance on their webpages.

Action Planned (AI summary) NHS England highlights existing national guidance on falls risk assessment and prevention, including NICE guidelines, and states that regional colleagues will engage with the Bath and North East Somerset, Swindon and Wiltshire System to ensure local leadership is embedding national guidance and best practice. DHSC notes that NHS England is responding to the report and highlights NICE guidelines and Royal College of Physicians guidance on falls prevention. They mention actions taken by Salisbury NHS Foundation Trust since the death, including an improvement programme to reduce falls, additional activities for patients at risk, and improved assessments on admission.

Action Planned (AI summary) Wiltshire Council will add 'SLOW' road markings to the Council’s road marking programme of works for the coming months. However, a review concluded that existing road sign arrangements are adequate, and no further amendments are proposed for signs.

Action Planned (AI summary) The hospital will provide training to staff on pre-alert calls for silver trauma cases by September 30, 2020, review the protocol for referrals to the Spinal Team via OARS (expected to take at least 3 months), and increase awareness of 'Dalteparin' guidelines. They also plan to share an internal investigation once completed.

Action Planned (AI summary) The CQC contacted South Western Ambulance Service NHS Foundation Trust for investigation reports and shared information from these cases with their national ambulance group. They also stated that a focus on cases involving apparent suicide in the presence of DNAR documents will be promoted for inclusion in future inspections of ambulance trusts. The Association of Ambulance Chief Executives (AACE), via NASMeD, has committed to reviewing and strengthening the JRCALC guidelines. This review will focus on the circumstances where resuscitation attempts should not be undertaken and the application of Do Not Resuscitate (DNACPR) forms, especially in cases of self-harm or overdose. South Western Ambulance Service NHS Foundation Trust has developed, launched, and disseminated a new Trust Guideline for DNACPR to its entire workforce. They have also strengthened communication links with mental health trusts and out-of-hours services, and plan to recruit a Senior Mental Health Practitioner to provide strategic leadership and develop further guidance and training. CQC is currently undertaking a thematic review of DNACPRs and will update its regulatory approaches, which may include strengthening how it regulates end-of-life care and DNAR/TEP forms. It will also share key learning and practice points from the inquest with inspectors. The Department commissioned the Care Quality Commission to review the use of DNACPRs, with the final report published in March 2021. The Department is committed to driving forward the implementation of the CQC's recommendations to address concerns.

Action Planned (AI summary) The UK government published its Online Harms White Paper which sets out plans for legislation to make the UK the safest place in the world to be online, establishing a new statutory duty of care overseen by an independent regulator with powers to issue substantial fines. The government has convened a working group of social media and digital sector companies to explore what more they can do to help keep children safe online.

Action Planned (AI summary) The Trust has updated the Root Cause Analysis investigation action plan and will implement electronic observations trust-wide by May 2018 with automatic escalation to doctors. The Royal College of Surgeons completed a review of Dr. Marshall's care; the Trust will review the report, consider recommendations, and develop an action plan.

Action Planned (AI summary) The council will commence stakeholder consultation on 18th September 2017 regarding proposals to improve pedestrian safety at the junction. Provisional arrangements have been made to assign resources to progress with the design and potential delivery of a scheme. The Department for Transport, while noting a lack of evidence, will consider with trade associations how to encourage signage on left-hand drive vehicles to alert pedestrians to the risks.

Action Planned (AI summary) The trust is working to improve the handover process with ambulance services, including plans for a new clinical note system including patient allergies. They are also exploring the IT infrastructure to improve information sharing and migrating the Emergency Department to the same server as the rest of the Trust.

Action Planned (AI summary) The care home outlines a process for managing residents requiring specialist equipment or interventions, including staff training, competency assessments, clear documentation, and reviews. This process will be communicated and implemented across all Avon Care Homes.

Action Planned (AI summary) A 20mph speed limit at Lockeridge is due to be completed by the end of 2016, including the provision of warning signs.

Action Planned (AI summary) Royal United Hospitals Bath NHS Foundation Trust (RUH) has implemented additional resource for Mental Health Services and amended the Mental Health Assessment Matrix. All junior doctors, Emergency Nurse Practitioners and Nursing staff receive training in the use and application of the mental health matrix at induction. Wiltshire Council describes planned discussions between Wiltshire Council (WC) and AWP to be held to clarify roles and responsibilities and ensure that a process is followed. Avon and Wiltshire NHS Trust highlights that the Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the CPA process including assessment of risk. The Trust CPA and Risk Training highlights the need for staff to include the views of service users and carers in undertaking any assessment.

Action Planned (AI summary) The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System (VELS) modification, aiming for completion by the end of 2016.