CQC

Action Planned (AI summary) PAGB will provide a written submission to the MHRA by September 30th, 2017 regarding paraffin-containing products and will work with the MHRA, fire brigades, and other stakeholders to ensure clear and consistent communication about the risks. MHRA has liaised with ArjoHuntleigh to confirm risk mitigation factors are appropriate and are working to communicate important healthcare information to healthcare professionals and the public through established alert systems. MHRA were also aware of and highlighted the work undertaken by the National Patient Safety Agency (NPSA) in 2007 regarding emollients. Locala has shared learning from the case internally, raised awareness about paraffin-containing products in their monthly medicines management report, and is developing a flowchart, documentation, and training for staff to identify patients at risk and ensure further risk assessments are completed when circumstances change. NHS Improvement notified of the death in 2015 and included actions taken in response to the death in the Patient safety review and response report published in June 2017. The UK Homecare Association has provided information to homecare providers including a fact sheet prepared by the London Fire Brigade, an article in their magazine, and an email briefing regarding the fire risks of paraffin-based emollients.

Action Planned (AI summary) The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face training time will reinforce this pathway in the months ahead and use of Vital Pac and the upcoming installation of new electronic patient record will provide decision support and alerts to reinforce standards.

Action Planned (AI summary) The Trust will include a statement in its search policy to enhance the definition of "belongings" to include items used to keep or transport belongings (e.g., bags). They have also commenced a process of implementation, including staff education and a clinical audit planned for April 2017 to evaluate effectiveness.

Action Planned (AI summary) The organisation plans to re-enforce the safeguarding policy, update job descriptions, include admission process under general screening, audit care plan, re-enforce home's protocols for unwitnessed accidents, plan training and supervision refresher first aid, review the home's management and on-call process.

Action Planned (AI summary) The Royal College of Radiologists will make its Fellows and members aware of the British Thoracic Society Pleural Disease Guidelines 2010. Following concerns about admitting acutely unwell patients without HDU/ITU facilities, BMI Mount Alvernia Hospital updated its admission policy to ensure all patients meet admission criteria. They also introduced mandatory training details for consultants and conduct monthly audits of consultant input into medical records.