2015

Noted (AI summary) NICE acknowledges the coroner's concerns about a lack of national guidance on VTE prophylaxis for patients in lower limb braces. NICE's clinical guideline (CG92) on VTE recommends mechanical VTE prophylaxis be continued until the patient no longer has significantly reduced mobility. They note that the guideline is to be updated and a new scope will be prepared as part of the process.

Noted (AI summary) The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, and information needs for NHS providers. It also highlights the existing out-of-hours Service Liaison Officer service and the MOD's commitment to the Mental Healthcare Crisis Concordat. The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies and procedures. The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to secure the MoD's commitment to the Mental Health Crisis Care Concordat by the end of April 2015. Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion with the MoD and will address the concerns raised in the report. Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and review patients who leave before being seen, also they updated policy to inform GP if patient fails to wait for assessment.

Noted (AI summary) Barts Health NHS Trust investigated the incident and has reminded staff of the importance of accurately changing patient details and the consequences of not doing so. They note that the patient did know about the follow-up appointment.

Noted (AI summary) The Highways Agency has extended a route safety study to consider whether a bridge at Elwick could facilitate closure of central reserve gaps, including the Dalton Piercy junction. The study is due to report in August 2015. Hartlepool Borough Council clarifies that the relevant stretch of road falls under the jurisdiction of Highways England, but they are in dialogue with Highways England and will assist as required.

Noted (AI summary) The CAA acknowledges the coroner's concerns but states that expert studies have not found a definitive link between cabin air quality and health issues. They will cooperate with EASA's ongoing investigations into cabin air quality and review their position in due course. British Airways notes the concerns but states that they have been fully dealt with by government and regulatory bodies. BA follows existing guidance and legislation and monitors research in this area.

Noted (AI summary) The HSE states it has no enforcement powers under the General Product Safety Regulations regarding showerheads and has passed the coroner's letter to the local Trading Standards Department. The council explains its duties under the Consumer Protection Act and General Product Safety Regulations, noting the absence of specific regulations for showerheads. They suggest the HSE review guidance regarding Legionnaires' disease and shower systems.

Noted (AI summary) The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the patient's notes as evidence.