Welsh Government

Noted (AI summary) The Welsh Government outlines its role in setting the strategic context for health services and holding NHS organisations accountable, noting that all health boards are in escalation for urgent and emergency care. They mention providing additional funding to Betsi Cadwaladr University Health Board and supporting improvement programs, but do not commit to specific changes in response to the report.

Noted (AI summary) The Welsh Government states that the A4059 is a local road and the responsibility of Rhondda Cynon Taf County Borough Council, and forwards the report's recommendations to RCTCBC.

Noted (AI summary) The Department for Transport acknowledges the concerns about e-cycle modification but states that existing regulations and enforcement powers are sufficient. They highlight regulations concerning e-cycles, the responsibilities of manufacturers and retailers, and the role of the Office for Product Safety and Standards and Local Authority Trading Standards.

Noted (AI summary) Bridgend County Borough Council acknowledges concerns about the A48 Laleston, Bridgend, but states existing signage and road markings meet regulations. The Council continues to monitor personal injury collision data and will implement measures to make the highways network safer where appropriate.

Noted (AI summary) Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act.

Noted (AI summary) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.

Noted (AI summary) The Welsh Government acknowledges the concerns raised about safety barriers. While noting the barriers met standards at the time of the incident, they commit to applying national standards, working with National Highways, adopting policy changes, and monitoring incidents.

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.

Noted (AI summary) Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and primary healthcare, and will discuss collaboration with CSSIW regarding communication between health services and care homes. Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients registering from nursing/care homes; they will audit the process in 6 months. Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the GP, and a specific proforma completed on discharge for patients from care homes; they investigated and addressed an incorrectly addressed discharge summary, noting improvements in access to the Welsh Clinical Portal. CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers relevant elements of care, and is satisfied that no additional policy change is required.