Mental Health related deaths

Noted (AI summary) The Department acknowledges the concerns regarding the 2010 Risk Assessment Tool for Venous Thromboembolism (VTE) and refers to NICE guidelines. They note the need for further research to balance VTE risk versus bleeding risk in acute psychiatric settings and that the National Patient Safety Committee will work to identify the best route to take this forward.

Noted (AI summary) NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing NICE and GMC guidance on sharing information and safe medicine use. The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health records and safe transfers of care. The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share learnings from the case with stakeholders and encourage pharmacies to work more effectively with healthcare teams. The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, RPS, and NHS England) to consider how practice can be improved.

Noted (AI summary) NICE acknowledges the concerns but states it cannot influence changes to the EMIS system. They highlight existing guidelines on medicines adherence (CG76) and depression management (CG90) that contain relevant recommendations. The RCGP will open a dialogue with the Royal Pharmaceutical Society to consider in more detail the issue of patients not collecting prescriptions, and recommends that much greater integration of pharmacy and GP IT systems will likely be needed. EMIS confirmed that their software was working as designed and complies with NHS Digital requirements and are presently considering a number of potential digital tools to aid further patient compliance; they welcome a discussion with stakeholders to create best practice for managing this risk. The practice uses EMIS Web software and outlines the three methods by which patients can request repeat prescriptions, also noting that there is no system to alert them if a patient is not requesting their repeat medications on a month-by-month basis and expressing concerns about the resources needed to respond to such alerts.

Noted (AI summary) The Trust states that all staff working with dementia patients have received appropriate training, and policies and guidelines are put into practice with staff receiving information and/or training on their implementation, and audits in place to monitor compliance. The Minister acknowledges the concerns, describes existing training frameworks and personalized care approaches, and mentions the Health and Care Bill's aim to improve integration of health and social care services.