2014

Noted (AI summary) HMP Woodhill staffing levels have been benchmarked and agreed upon, with ongoing local and national recruitment efforts to address vacancies. Information sharing between prison staff and contractors is a priority.

Noted (AI summary) The Royal College of Anaesthetists will ensure particular attention is attached to correct site location at the next curriculum review. They have also issued an alert to their network of senior anaesthetists and requested reports related to chest drain insertion incidents be forwarded to them. The British Thoracic Society notes the concerns and refers to their existing guidelines on safe chest drain insertion, highlighting that these are more comprehensive than the NPSA information. They are unsure if local guidelines were available at the Trust where the event occurred. NHS England has established a Reference Group to develop National Standards for Operating Department Practice by early 2015. If North Bristol Healthcare NHS Trust shares its checklist, there may be an opportunity to include it as a resource for other Trusts when the standards are implemented. The College of Emergency Medicine will highlight the case and investigation findings in its next Safety Newsflash and share the North Bristol NHS Trust's safety checklist and guidelines on their website once received.

Noted (AI summary) The Royal College of General Practitioners provides information on its role and remit, and references existing guidance and resources related to the concerns raised regarding referral letters and communication with secondary care. The Trust has revised its referral form to improve the quality of information GPs provide, including asking for more detail and highlighting the need to exclude organic causes of weight loss prior to referral to the Eating Disorders Service. The trust has also shared the concern about hospital notes with their medical records team. The Royal College of Psychiatrists agrees with the need for better EDS proformas. They highlight concerns about risk assessment in psychiatry and the need for eating disorder specialists with adequate medical training. The college plans to raise these issues at the next Executive Committee Meeting and will ask for consideration on how best to disseminate robust EDS proformas across the UK health economy. The surgery will ensure all consultations are fully documented in patient notes and proper assessments are conducted. All GPs will complete the BMJ online learning e-module on hyponatraemia. A consultant endocrinologist will give a lunchtime educational meeting at the practice on hyponatraemia and Addison's Disease. All patient referrals will have copies of all investigations attached.

Noted (AI summary) The Department of Health notes the concerns raised regarding the NICE guideline CG63 and its review. They state that draft guidance is due to go out for consultation in September 2014 and the finalized guidance is expected to be published in February 2015 and that there is no scope to expedite the process.

Noted (AI summary) The Trust replaced wall-mounted alcohol-based hand sanitiser dispensers with alcohol-free alternatives and raised staff awareness of the risks associated with ingestion of alcohol. The Department of Health acknowledges the concerns and points to existing national guidance on suicide prevention and risk assessment in mental health services, but doesn't describe specific actions taken or planned in response to the report.

Noted (AI summary) The Department of Health acknowledges the concerns regarding the sale of helium gas and references a previous response to a similar case. They provide a copy of that earlier reply.