Central and North West London NHS Foundation Trust

Action Taken (AI summary) The hospital has updated its Police Custody SOP, incorporated Emergency Department-specific guidelines, is reviewing training on restraint and restrictive practices, and has reiterated Toxbase guidelines to clinicians. Breakaway and conflict resolution training remains mandated. The trust has implemented a joint entry protocol for documentation, mandating verbal handovers post-assessment and reinforcing the principle that discharge from ED should not proceed with unresolved safety concerns. Refresher and Human Factors training are also taking place. Thames Valley Police has reviewed training material on handcuffing, implemented additional Personal Safety Training, provided training to officers on medical issues that can arise with prolonged restraint, rolled out the College of Policing's 'Upstander' E-Learning, and included communication and handover protocols in training scenarios.

Action Taken (AI summary) The Trust is transferring the Speech and Language Therapy service to Milton Keynes University Hospital on 22 October, enhancing training to include practical elements, and working with the hospital on a quality improvement initiative focused on dysphagia care. A new electronic referral process has been implemented to ensure referrals are standardized and can be triaged effectively. The hospital is running a Quality Improvement Programme focused on dysphagia management, delivering a Fundamentals of Care training programme for all clinical staff, and working to improve access to patient records across different systems. The SALT service will transition in-house at MKUH.

Action Taken (AI summary) The Trust has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement, including meetings with staff, strengthened induction for temporary and new staff, and realigned the Nurse in Charge role. The Trust Resuscitation Group has also developed a visual aid for oxygen cylinders and distributed written communication to staff.

Action Taken (AI summary) The Trust has taken action to improve staff training in emergency response, including additional in-situ simulation sessions and building a simulation room. Learning from simulations is shared via team meetings and presented to the Resuscitation and Deteriorating Patient Committee.

Action Taken (AI summary) The Trust acknowledged failures in care and has re-trained staff in wound management, including the use of the NEWS2 tool for deteriorating patients. They will also conduct a 3-month action plan to ensure improvements are embedded, including improved communication and escalation procedures with specialist services and GPs.