2014

Action Taken (AI summary) The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.

Action Taken (AI summary) HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change.

Action Taken (AI summary) Sapper Gibson's unit now holds keys to all buildings and rooms in the guardroom. The MOD is updating its Health and Safety risk assessment guidance to ensure site risk assessments consider rapid access to locked rooms, and procedures are tested regularly; the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that master or spare keys to all rooms will be held centrally in the guardroom (or similar where there is no guardroom).

Action Taken (AI summary) HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested in all cases with health concerns, and all new healthcare staff are shown how to use the SystmOne electronic record system correctly.

Action Taken (AI summary) University Hospitals of Leicester NHS Trust has established a process where each RCA investigation has a named 'Chair', introduced RCA Oversight training for RCA Chairs, and established a new 'Adverse Events Committee' to review all serious untoward events (SUIs).

Action Taken (AI summary) The Trust reviewed and reinforced procedures for sharing information with new service providers when patients relocate, including requesting GP details and sending discharge notifications. They have also logged the issues in their corporate action plan and will share learning through quarterly events.

Action Taken (AI summary) The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This aims to provide clinical support for patients waiting longer than 8 minutes and improve the ambulance performance standard.

Action Taken (AI summary) The Trust conducted an investigation and implemented a Trust-wide action plan, including spot checks on wards, a specific training program for recognizing deteriorating patients, and ensuring effective communication. They have also improved handover procedures, developed service excellence training, and presented the case as a learning opportunity at a Clinical Governance Day.

Action Taken (AI summary) The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds.

Action Taken (AI summary) Bexley Children's Services have implemented lessons learned into social work practice, and a triage system is in place for when looked after children go missing. A risk assessment report is required in preparation for strategy meetings for missing looked after children, and strategy meetings are held within three days of a child going missing. Greenwich Police enclosed a report detailing their actions, addressing information sharing and risk assessment, as well as their broader response to the serious case review that followed the death. Their response has been reviewed to ensure that measures introduced following the serious case review account for issues raised in the report and are fully embedded in current practice. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing.

Action Taken (AI summary) The Trust has begun a high-risk review into the death and is improving electronic reporting systems by utilizing a system called "Order Comms" for radiology. The Matron for the CDU has ensured that the staff are familiar with the responsible flowchart. The process for discharge summaries with patients from the CDU is currently under review and it is anticipated that the CDU will soon be utilising the electronic discharge summary process.

Action Taken (AI summary) Following the inquest, the individual nurse received capability management and observed best practices. The Trust is reviewing policy and practice, planning further suicide prevention training, and monitoring implementation via the Directorate's Quality Assurance Group. Trust-wide actions will be allocated to an owner and monitored by the Patient Safety Team.