2014

Action Planned (AI summary) Luton CCG will share findings with Luton Clinical Commissioning Group, LHS has accepted NICE Guidance CG176, LHS will cooperate with NHS England investigation and is resubmitting its 'Risk and Serious Incident Framework' for scrutiny, key priority will be review of emergency and urgent care commissioning arrangements.

Action Planned (AI summary) The Council will install a timber barrier in the riverside footpath adjacent to the wall opposite the exit of Drury Lane. The County Council will also be undertaking a risk assessment along sections of the river bank.

Action Planned (AI summary) Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors in July 2014 and ensure practice pharmacists review and improve medicines reconciliation processes starting in July 2014. Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance of communication. They will also take this to the Mental Health Partnership Board to highlight the communication lessons.

Action Planned (AI summary) A solution is being rolled out in three phases to improve communication of discharge information between the hospital and GPs, including remote implementation, training, IT support and standard operating procedures. They are awaiting confirmation from Western Cheshire, South East Staffs and Seisdon; Shropshire and Vale Royal and South Cheshire to commit to the plan.

Action Planned (AI summary) Camden Council will issue a brief to traffic consultants by the end of May 2014 to invite tenders for traffic signal modelling in the Holborn area, including the Southampton Row/Vernon Place junction, with consultants expected to be appointed in mid-June 2014.

Action Planned (AI summary) DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations.

Action Planned (AI summary) The National Ambulance Sector will require the use of either a digital ETC02 monitoring device or full waveform capnography for every intubation with immediate effect. Waveform capnography will be considered the gold standard and the sector is committed to having this in place on every responding vehicle crewed by a paramedic by July 2017.

Action Planned (AI summary) CQC will disseminate the coroner's report within the CQC, particularly in relation to inspections of hospitals, and feed the issues into intelligent monitoring systems and key lines of enquiry. They will also consider improvements that have been implemented by the trust.

Action Planned (AI summary) Stockport CCG is seeking formal assurance from Mastercall regarding processes for new starters and contingency plans when practitioners lack smartcards. They will also work with Mastercall to map and analyze processes for accessing shared records and to ensure fit-for-purpose mobile solutions with access to necessary information. Stockport CCG are investigating the attempted access to the patient's record at the time of the incident and are working with suppliers to understand the root cause and whether it was a human or system error. The CCG has also written to Mastercall to arrange a meeting to understand the issues more fully, and improve processes for the reporting of issues relating to the SHR.