Other related deaths

Action Planned (AI summary) Specsavers will commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar available to all professional staff within the Company. They also hope to make the training available for the wider optical community.

Action Planned (AI summary) NHS England published the NHS Long Term Plan which has a clear commitment to improve the outcomes for those with a respiratory condition including asthma. NHS England and NHS Improvement commission the National Asthma Audit Programme that provides data on a range of indicators to show improvements and opportunities in asthma outcomes.

Action Planned (AI summary) The MHRA sought advice from the UK Commission on Human Medicines (CHM) on a range of areas to support the effective and safe use of AAIs. The AAI EWG recommended a number of other measures including reinforcement of the need for all patients at risk of anaphylaxis to carry two AAIs at all times. The FSA is undertaking consumer research to gather information and insights from people with food allergies and is considering the benefits of developing a food allergy safety scheme for allergen management within food businesses. They are supporting businesses to prepare for new allergen labelling rules coming into effect on 1st October 2021. The FSA is establishing a way for people to directly report information regarding anaphylactic reactions caused by food allergies that do not result in death. The MHRA is considering making AAI devices more widely available for use in exceptional, emergency situations.

Action Planned (AI summary) NHS Digital will bring the circumstances surrounding the death to the attention of a programme that is rationalising and streamlining the systems and data flows in the management of primary care registration. This is so that improvements may be considered through appropriate consultation with system users and stakeholders.

Action Planned (AI summary) Jet2.com has updated its Ground Handling Manual to include procedures for supporting vulnerable passengers, including contacting family/friends, embassies, or other services. Training will be updated using the case as a study, and the CAA has approved the amended procedures. The Civil Aviation Authority (CAA) will explore how to define vulnerable consumers, propose improvements to their treatment in the UK aviation industry, and increase engagement with industry. The CAA Executive will receive a report in Q1 2021 and review progress regularly.

Action Planned (AI summary) The department will raise the concern that the statutory minimum provision of smoke alarms is less than the maximum offered in British Standard 5839 with the relevant committee at the British Standards Institute for consideration, as part of a full technical review of the standards that support building regulations.

Action Planned (AI summary) Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.

Action Planned (AI summary) Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, and shared nationally, and will also be incorporated into their Olive Branch training sessions.

Action Planned (AI summary) The Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group to develop an Action Plan addressing the management of anticoagulation in patients over 65 who sustain a head trauma; an update is promised by the end of March 2021. The Trust has completed updates to the Falls Prevention policy, quick reference guides, and Nerve Centre software; mandatory questions have been added to the Datix incident management system, and the action has been formally added to the Trust's Strategic Quality Improvement Programme and Corporate Risk Register.

Action Planned (AI summary) Meade Close Care Home has provided additional training to all staff on identifying risks and escalating concerns, as well as on safeguarding adults and children, basic life support, and first aid. They have also completed a lessons learned log and shared it with Trafford Metropolitan Borough Council. Trafford Council reiterated PPE guidance and will conduct bi-annual audits to ensure adherence, monitored via a specific audit tool and annual quality review.