Child Death

Action Planned (AI summary) EMAS will be sharing updated guidance, national PGD and learning from this PFD across the Ambulance Pharmacists Network. Updated guidance and training package is being developed and will be rolled out during 2022/23 which will include the option for clinicians to administer buccal midazolam to adults (18 years and over) who present with convulsive status epilepticus when it is not available within the home as a prescribed medication.

Action Planned (AI summary) DHSC notes that £52 million was announced to fast track the provision of online maternity records and NHSE has updated the maternity early warning score (NEWS2) chart and the updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction. A standardised risk assessment tool that all trust should use at the onset of labour has been developed.

Action Planned (AI summary) Govia Thameslink Railway will use output from Operational Development Days to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare. This will reinforce the need to contact the BTP to frontline teams via training and staff briefings, supplementing the Samaritans TACTIC booklets. Network Rail and Govia Thameslink Railway have jointly created a new section within their joint incident management standard for dealing with vulnerable people. They have briefed all control room staff with the 'Concern for Welfare' briefing and shared it internally with all route controls nationally.

Action Planned (AI summary) Harden & Bingley Park Ltd will erect more signs around the Goit Stock waterfall area, and has provided photos of the proposed signs.

Action Planned (AI summary) Norfolk County Council reduced the speed limit to 50mph in response to this incident and will undertake speed surveys to measure driver compliance, and will undertake a further review to reassess the visibility approaching the A134 from the northeast arm of the junction.

Action Planned (AI summary) The Trust is developing an updated electronic risk assessment proforma to prompt a review of the existing safety plan. The Trust will update its training for all staff in relation to the importance of safety plans and contingency planning and has arranged a meeting with the family to share learning and provide further reassurance in respect of improvements made within the service.

Action Planned (AI summary) The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are piloting the provision of portable induction loops to assist tenants with hearing impairments.

Action Planned (AI summary) The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support.

Action Planned (AI summary) The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP.

Action Planned (AI summary) The paediatric team is developing a 'Paediatric Advice Proforma' on the Trust's electronic Iportal system to aid documentation of conversations between hospitals and an associated Standard Operating Procedure. Royal Stoke has appointed a named Consultant to manage children with metabolic disease. The Trust is working to transition to the most recent version of the Norse system, which will include features to document patient observations and communication between clinicians. They will also remind clinicians to keep contemporaneous notes about advice given to district general hospitals.

Action Planned (AI summary) DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.