Cwm Taf Morgannwg University Health Board

Noted (AI summary) The Health Board now contacts the Assistant Medical Director for Professional Regulation and Standards to check for ongoing GMC concerns when a doctor leaves. The GMC states that its statutory powers only extend to doctors registered with the GMC, the Medical Act makes provision to erase doctors who fail to maintain an effective registered address, international regulators have data sharing practices, and information about a doctor's fitness to practise history can be publicly accessed on the online register, LRMP, therefore no further action is required.

Noted (AI summary) The Welsh Government will discuss the incident at the all Wales Serious Incidents Group in October to improve learning and develop/disseminate further guidance across professional groups. They will also keep the case under ongoing review. The University Health Board has implemented a safe system of work for recording items stored in patient PODS, disseminated risk management policies via ward meetings with staff sign-off, and is developing a standard list of documents for disclosure at inquest. NHS Improvement supported the MHRA by searching the National Reporting and Learning System, which reinforced the importance of annual eye screening for patients on long-term Hydroxychloroquine. They stand ready to support the MHRA in ensuring any future changes to monitoring reach healthcare professionals. The MHRA acknowledged the concerns and requested further information regarding the case to determine if regulatory action is required, including observed drug concentrations, symptoms of overdose, concomitant medications, post-mortem sample details, and renal/liver function test results. NHS England is working to ensure that by 2020/21, 280,000 more people with serious mental illness have their physical health needs met. NHS Improvement issued an Estates and Facilities Alert on 'Assessment of ligature points' on 19 September 2018.