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) 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) The government extended the Dangerous Dogs Act 1991 to cover all places, including the owner's property, and increased penalties for fatal and non-fatal attacks. Compulsory microchipping of dogs will be introduced in April 2016.

Action Taken (AI summary) The health board now has a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours so socially anxious patients could be assessed at the Unit. The adoption of an electronic case record is currently being explored.

Action Taken (AI summary) The Priory Group audited the competencies of medical staff in specialist wards and provided additional training where needed. They are ensuring a full baseline physical health assessment is in place at the point of admission. They reviewed practices and will ensure that all hospitals have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs.

Action Taken (AI summary) The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed and training for nursing staff has been reviewed to include the management of allergies.

Action Taken (AI summary) Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users after incidents, and making referrals.