2014

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) Yorkshire Ambulance Service reviewed training for EMD staff, clarified management involvement in 'stand off' decisions, and reinforced consideration of alternative support methods. They are also reviewing the meal break policy to balance staff needs and patient safety, and have reminded staff about incident reporting procedures.

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) PECS has reviewed its contractors' operational policies to ensure staff understand and adhere to the requirement to share Prisoner Escort Records (PER) with relevant parties, including Youth Offending Services, and has reminded Geo Amey of this requirement. This will be reinforced in staff briefings and safer custody training.

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.