2013

Noted (AI summary) The GMC acknowledges the concerns but states that statutory rules preclude them from investigating events that are more than five years old and they have not received any further complaints since 2007.

Noted (AI summary) Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan.

Noted (AI summary) The Department for Education acknowledges the concern about paediatric first aid training and states that it is a statutory requirement for early years providers. They are consulting on reinforcing the need for a first-aid trained member of staff to be available at all times and expect to publish the results in February 2014. NWAS describes its recruitment and training processes for Emergency Medical Dispatchers (EMDs), including a six-week training course and continuing education requirements. All EMDs are required to undergo CPR recertification every two years. The Department of Health acknowledges the concerns, notes that training of nursery staff is the DfE's responsibility and NWAS is responsible for selection/training of call takers. They report that NWAS vehicles are equipped with paediatric equipment and they will share the report with the Association of Ambulance Chief Executives.

Noted (AI summary) The Trust reviewed records but states it is unable to respond fully to the concerns due to a lack of clarity regarding the patient's condition in the months before his death. They offer to remind medical teams about antibiotic administration options.