2015

Noted (AI summary) Leicestershire Partnership NHS Trust has implemented a robust system for seeking clinical information and has a flowchart identifying team member responsibilities. However, following review of the case notes, it was felt that anti-depressant medication was not clinically indicated and therefore an opportunity to restart medication was not missed. HM Prison and Probation Service has reinforced local policies to ensure ACCTs are opened on reception after a self-harm attempt, launched a new Safer Prisons strategy, provided training on recording risk information, and established a Safer Custody team. They have also reminded staff about comprehensive risk assessments and individual responsibility for safer custody.

Noted (AI summary) The Welsh Government reviewed its guidance leaflet for parents on reducing SUDI risks following the coroner's concerns, but concluded that the leaflet should continue to be used without changes, consistent with NICE guidance.

Noted (AI summary) The Department for Communities and Local Government does not consider building regulations to be the best way to ensure swimming pool safety, as regulations apply only where building work takes place and cannot be applied retrospectively. They expect owners/occupiers to be responsible for safety on their property.

Noted (AI summary) Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and will pass the case for a decision by January 8, 2015. The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write to the referring party with their decision.

Noted (AI summary) Bedford Hospital NHS Trust explains its procedures for newly qualified midwives, neonatal resuscitation training, and supervision of midwives, asserting compliance with relevant standards and effective operation of the supervision system. They state that there were no issues raised by the LSA officer to date.

Noted (AI summary) Avon and Wiltshire NHS Trust explains its process for managing bed pressures and out-of-area placements, stating decisions are risk-based. They also note their surprise at receiving a PFD report for an inquest where they weren't a properly interested party.

Noted (AI summary) The Environment Agency explains its flood warning system and provides a direct warning service to those who sign up when the river level exceeds 2.7m ALD. They provided a technical note to Shropshire County Council to help them implement a system for closing the gate at Dorset Street using live river level information. Shropshire Council is looking to provide CCTV cameras, one looking up from the Railway Bridge to the English Bridge, one looking down the Weir. The Town Council are halfway through a programme of upgrading the light and have increased the number of columns.