2014

Action Taken (AI summary) Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.

Action Taken (AI summary) The Queen Elizabeth Hospital has implemented clear guidance for doctors on investigating patients admitted after pacemaker insertion and implemented a system for cardiac technicians to directly contact clinical teams about abnormal results. The hospital is moving to an electronic reporting system and cardiology consultants are routinely present on site on weekends.

Action Taken (AI summary) Bupa acknowledges that CPR was not carried out when it should have been. Following the incident, Ardenlea Grove Nursing Home has reappraised procedures and processes for life support, and has provided a suction machine on each floor.

Action Taken (AI summary) Following a fatal collision, the council undertook surveys and implemented a reprofiling scheme funded by the Welsh Government. They also introduced double solid white centre lines and additional warning signs, plus verge marker posts.

Action Taken (AI summary) NHSBT has already taken action, including a review of the incident, sharing learning points with specialist nurses, hosting a working group to reduce recurrence risk in March 2015, and commencing a monthly audit to review primary records for organ donors.

Action Taken (AI summary) Norfolk County Council has taken action regarding the individual worker involved and the Adult Social Services Quality Assurance Team is developing a Best Practice factsheet to formalise local custom and practice regarding contacting people referred to the Service.

Action Taken (AI summary) Following the death, Basildon and Thurrock University Hospitals NHS Trust undertook an investigation and developed an action plan. Actions include appointing a Risk and Document Control Manager, overhauling NPSA Alert dissemination, and strengthening nasogastric tube training with designated assessors and monthly compliance reports.

Action Taken (AI summary) Bridgewater Community Healthcare NHS Foundation Trust has taken several actions, including updating the Out of Hours Triage Policy, developing a Paediatric Early Warning System (PEWS) and escalation aid, and delivering training on recognising serious illness in children.

Action Taken (AI summary) The police force has introduced an electronic system which sweeps all police incident logs every ten minutes and sends an immediate alert to the Firearms Licensing Unit if any log relates to an existing certificate holder. Written working practice is also being developed to formally capture the existing process for reviewing restricted logs.

Action Taken (AI summary) Following an investigation, the Trust identified variations in paracetamol prescribing across the organisation, and the Medical Devices Committee and Medications Safety Group have thoroughly reviewed the prescribing process. The Trust has revised its practice to ensure regular monitoring of patients prescribed Paracetamol, communicated via SBAR slides distributed to medical staff and incorporated into the Medicines Management e-learning module.