Emergency services related deaths

Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.

Noted (AI summary) NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve information sharing and mental health services.

Noted (AI summary) The Clinical Commissioning Group provides information and context regarding the MPDS algorithm, the identification of ineffective breathing, ambulance performance data, and staffing levels within NWAS, without stating planned actions. NHS England will hold a learning event with all ambulance services and triage system providers to share best practice and ensure ambulance services utilise triage systems safely and effectively in identifying ineffective breathing in asthma patients.

Noted (AI summary) West Midlands Ambulance Service took immediate action by informing all frontline staff of requirements for medical gas cylinder assembly/disassembly and sharing lessons learned with partner organizations. The CQC acknowledges the concerns but states it is outside of their remit to issue or change formal guidance or policies around oxygen usage or safety, as they are not clinical experts. They will continue to communicate with WMAS and monitor actions taken to improve safety. HSE will support MHRA as the lead authority and will use its communication channels to promote any information/guidance produced by the MHRA. They will also consider if HSE guidance document INDG459 should be updated to reflect any new information/guidance produced. MHRA has commenced a dialogue with the Association of Anaesthetists and the Safe Anaesthesia Liaison Group of the Royal College of Anaesthetists to raise awareness of ignition within valve components of oxygen cylinders. MHRA was represented on a multiagency group which hopes to publish guidance once ratified by the Councils of both the RCoA and the AA.

Noted (AI summary) Yorkshire Ambulance Service NHS Trust will audit patients treated at home to gather feedback on information provided, review the PIL template content, conduct spot audits of care plans, launch a communications campaign for staff on detailed care plans for non-conveyance, and develop tick-box indicators on the EPR. The future intention is to embed the PIL content into the EPR and email it to the patient and their primary care provider. The National Medical Director describes existing NHS Pathways triage processes, including the use of a standard set of questions and validation of information by clinicians. They state that shared care records allow clinicians to access information on long-term conditions, medical history, medications, and allergies.