NHS England

Noted (AI summary) NHS England outlines actions taken to improve ambulance performance, including implementing the Delivery plan for recovering urgent and emergency care services, engaging with West Yorkshire ICB, and publishing the NHS Long Term Workforce Plan. These actions include joint escalation processes, investment in resources, and workforce enhancements. West Yorkshire ICB describes actions taken to reduce ambulance response times and handover delays, including funding for additional resource in call centres. The ICB also highlights the development of a System Coordination Centre (SCC) to enable a proactive system response to operational pressures. The DHSC acknowledges the concerns regarding ambulance response times and hospital handover delays, notes that West Yorkshire ICB and NHS England will respond directly on specific actions, and highlights national initiatives to improve urgent and emergency care performance.

Noted (AI summary) The Royal College of Emergency Medicine notes the coroner's concerns about delays in VTE risk assessment but states that this is the responsibility of admitting specialties, not emergency medicine doctors, once a patient has been seen by another team. NICE acknowledges that its current VTE guidance does not cover people in the emergency department prior to admission and will ask its prioritisation board to consider if guidance should be developed in this area. NHS England has contacted NICE to suggest updating their guidance on VTE assessments to recommend that they should be undertaken within 14 hours of a 'decision to admit', as opposed to admission, to account for ED wait times. Firmley Health NHS Foundation Trust will revise its VTE policy to require risk assessment within 2 hours of arrival in the Emergency Department, with a clinical review within 12 hours if the patient remains in the ED. They will also add a prompt to their electronic record system and communicate the changes Trust-wide, aiming to complete these steps within 12 weeks. The Royal College of Physicians will produce a Safety Alert for Physicians and liaise with national clinical directors and The Society for Acute Medicine regarding delays in VTE prophylaxis due to hospital admission delays.

Noted (AI summary) NHS England acknowledges concerns about staffing issues and winter pressures, highlighting the Long-Term Workforce Plan and ongoing planning for winter pressures, and refers the coroner to NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust for local arrangements. Birmingham and Solihull ICB and University Hospitals Birmingham have appointed three locum consultants and an academic colorectal consultant, created a Surgical Workforce Taskforce and are implementing the 4Rs Workforce Delivery Framework. The Department of Health and Social Care acknowledges concerns about winter pressures and staffing shortages, highlighting NHS England's delivery plan for recovering urgent and emergency care services and the NHS Long Term Workforce Plan, while noting Trusts' responsibility for safe staffing levels.

Noted (AI summary) NHS England will work towards surfacing inclusion data to patients via their NHS App and will promote the Digital Clinical Safety Strategy. They also state that all reports received are discussed by the Regulation 28 Working Group. Cegedim plans to consider implementing functionality to take patient age into account when recording weight or height for BMI calculation in future Vision clinical system updates. EMIS acknowledges the coroner's concerns and states that their EMIS Web system has inbuilt safety principles and complies with NHS specifications. They will continue to review their solutions but believe no further software developments are required. TPP acknowledges the concerns regarding BMI calculations in GP IT systems but states that the erroneous entry was made on a previous system and that the current system, SystmOne, has validation in place for height and weight measurements. They suggest national-level requirements for BMI validation to ensure a consistent approach. The RCGP will ask the GPITC to discuss the concerns at their next meeting in July 2024 and will ask NHS England to consider coordinating funded clinical safety workshops. They will highlight the importance of accurate data entry through their continuing professional development program for members. The BMA will discuss the concerns at their next Joint GP IT Committee meeting to raise awareness and seek consensus on how systems might evolve. They will also advocate for improvements in NHS IT systems so patients have greater confidence in treatment decisions.

Noted (AI summary) NHS England states that the responsibility for clinical guidelines lies with NICE and the Royal Colleges, and highlights existing guidance from those bodies on AAA and acute pancreatitis. They note internal discussions and the sharing of learning from PFD reports nationally. NICE will review and consider changing the wording in section 1.2 of its guideline on pancreatitis regarding the confirmation of diagnosis by testing blood lipase or amylase levels. NICE has amended its guideline for pancreatitis (NG104) to clarify the interpretation of blood lipase or amylase levels in diagnosis.

Noted (AI summary) NHS England outlines key actions from their Delivery plan for recovering urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity, improving hospital flow, speeding up discharges, and expanding community services. They also mention the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The DHSC acknowledges concerns about ambulance response times and hospital handover delays, directing the coroner to NHS England and Birmingham Integrated Care Board for specific actions. They highlight the 'Delivery plan for recovering urgent and emergency care services' and funding allocated to boost ambulance capacity and improve patient flow. NHS Birmingham and Solihull outline several actions to address ambulance delays, including the implementation of a medical push model, improvement activities to reduce length of stay, and a single transfer of care hub. These measures aim to improve patient flow out of acute hospitals.

Noted (AI summary) NHS England references the Long-Term Workforce Plan and actions to increase domestic education, training, and recruitment, as well as improve culture and retention. The response also highlights the use of AI and investment in pathology and imaging networks to increase productivity. The Department acknowledges the concerns about Consultant Histopathologist shortages and refers to NHS England's response. It cites the NHS Long Term Workforce Plan's goals to increase medical school places and grow the NHS workforce, and notes the increasing number of histopathology consultants and trainees.

Noted (AI summary) NHS England acknowledges the concerns regarding epilepsy patient reviews and medication management, highlighting existing NICE guidelines, RCGP eLearning resources, and tools for structured reviews. They note workforce capacity challenges and share the report with regional colleagues, also describing the Regulation 28 Working Group. The Royal College of Physicians supports the Association of British Neurologists' position regarding national guidance on epilepsy monitoring, annual follow-up in primary care, and the need for clear communication in discharge letters. They highlight the low number of neurologists and epilepsy specialist nurses in the UK. The RCGP plans to highlight NICE guidelines and educational material on SUDEP through its Clinical Networks and member forums. It will also recommend to NHS England the need for standardised urgent care pathways for epilepsy patients and address issues relating to waiting times for appointments.

Noted (AI summary) NHS England acknowledges the concerns and refers to actions taken by Norfolk and Suffolk NHS Foundation Trust, including a Quality Improvement Programme, re-evaluation of training, a new SOP, and changes to the Patient Safety Screening Form. They also describe the PSIRF and its aims. Following concerns raised, the Trust has added prompts to the patient safety screening form to consider retrieving patient calls for investigation and inquest purposes. Additionally, they have extended their current recording facility in one of their CRHTT areas which went live on 15th May 2024 and have enabled phone lines designated as requiring a recording facility.

Noted (AI summary) NHS England is working with private sector organisations to trial the use of Summary Care Records in settings where they have previously been unavailable and will continue this work throughout 2024. They also note the responsibility of providers to share information under the Health and Social Care (Safety and Quality) Act 2015. The CQC states they cannot comment on the regulation of the private psychotherapist as the practice is not registered with CQC. They welcome the action taken by Surrey and Borders Partnership NHS Foundation Trust and will continue to monitor the trust and any new information received but state this is outside the scope of their regulatory powers. The UK Council for Psychotherapy outlines its role and regulatory responsibility, noting its register of psychotherapists and Complaints and Conduct Process. They state they will not take action in relation to the coroner's first concern, but note work with the Professional Standards Authority and the NHS in discussing opportunities for collaboration in support of suicide prevention strategies.

Noted (AI summary) NHS England acknowledges the coroner's concerns, notes that the BSG is updating guidance, and states they will support the implementation of any changes; they have shared the report with relevant NHS Trusts and ICBs and are monitoring reports nationally. NICE acknowledges the coroner's concerns and notes that the relevant CKS is being updated by Agilio Software; NICE will consider the issues raised through its guideline surveillance process. The BSG plans to issue a statement to members and publish a journal letter regarding management of patients with coronary stents on anticoagulants needing endoscopy, recommending switching to aspirin or discussing with interventional cardiology.

Noted (AI summary) NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit of the named NHS Trust. They confirm the concerns have been shared with their national Mental Health Team and Regulation 28 Working Group. The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication amongst professionals involved in treatment.

Noted (AI summary) NHS England acknowledges the concerns regarding neurology department pressures and neurologist shortages. They highlight the GIRFT program and national work on workforce wellbeing, but note that safe staffing is the responsibility of individual trusts. They are engaging with the Mid and South Essex NHS Foundation Trust regarding their Serious Incident Review and action plan. The Trust acknowledges concerns around delays in neurology referrals and inappropriate telephone consultations during the pandemic, but attributes some issues to external services and COVID-19 restrictions. They have undertaken several actions, including policy reviews, audits, training, and investment in neurology services to address these issues. They have also reached out to NHS England about the shortage of neurologists and are waiting for national guidance.

Noted (AI summary) NHS England states that all NHS services have access to the 'Service Finder Tool' which offers health and social care professionals accurate and up-to-date information, including contact details. It also notes the NHS Long Term Plan recognised the crucial role of community mental health services.