Tameside and Glossop Integrated Care NHS Foundation Trust

Noted (AI summary) The trust clarifies that no serious incident investigation was undertaken and no follow-up appointment was made in the fracture clinic as no fracture was identified. They describe current protocols for wound management including regular team meetings and monthly masterclass sessions.

Noted (AI summary) The Department of Health and Social Care outlines the planned phased implementation of Martha's Rule, giving patients the right to request a rapid review of their case by someone outside their immediate care team, and describes NHS England's broader Managing Deterioration Safety Improvement Programme. The response contains no text and cannot be classified.

Noted (AI summary) NHS England acknowledges the concerns and states that the Tameside and Glossop Integrated Care NHS Foundation Trust is the appropriate organisation to respond. They note the Trust's response addresses the concerns and that they have been implementing improvement work. The Critical Care Unit has amended their daily review chart to provide additional clarity and comprehensive documentation regarding referrals to the Liver Unit. Also clinical induction training includes intravenous (IV) cannulation for all registered staff.

Noted (AI summary) The response acknowledges the concerns raised and references actions taken by Tameside and Glossop Integrated Care NHS Foundation Trust, including a Root Cause Analysis and increased medical rota. It also notes that the CQC received assurance regarding a review of the sepsis pathway and retraining for staff. The Trust is planning to pilot an eNEWS application across its surgical wards to improve the accuracy and speed of data recording and to eliminate errors in early score warning calculation. The Trust's incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting.

Noted (AI summary) Learning from this case will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums to improve outcomes for the population of Greater Manchester. Response contains no content.

Noted (AI summary) Tameside and Glossop Integrated Care NHS Trust states that the referral to District Nurses was made by hospital staff, contrary to evidence heard. They outline the Trust's processes for using Bank and Agency staff to fill vacancies and their recruitment/retention efforts.

Noted (AI summary) Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high levels of needs like Mr. Jennings as they consider them covered by existing secondary care services. They will follow up on the other concerns with Pennine Care Foundation Trust through quality and performance monitoring. The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar programme. It also mentions the Healthcare Safety Investigation Branch's investigation into care for patients with mental health problems in emergency departments. NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals (updated Emergency Department module in Lorenzo with mandatory data collection fields).

Noted (AI summary) The Department of Health issued an Estates and Facilities Safety Alert to the NHS in England regarding the speed of closing fire doors. The alert sets out necessary action to be taken to reduce the risk of similar incidents in the future and covers all self-closing fire doors. The trust states that the incident didn't invoke the Statutory Duty of Candour. The trust states they have been proactive in relation to ensuring Duty of Candour and gives information about training workshops.

Noted (AI summary) The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified as a result of the Trust's response and will reinforce the duties of the Trust in relation to its duty of candour. Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A system for the urgent recall of patients discharged with potentially life-threatening conditions has been addressed by the Patient Flow Manager.