2015

Action Taken (AI summary) The Trust updated its Observation and Engagement of Service Users policy and communicated changes to staff. Additional height bars were added to a railing on the disabled access ramp and the Trust has decided to enclose the ramp, with work scheduled for completion by the end of March 2016. The Trusts have worked together to develop a process for ensuring that patients under the care of mental health services who require acute care have a clear pathway which includes agreed communication channels between clinicians. A flow-diagram has been developed and is being used. The hospital has worked with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway to ensure inpatients from the local mental health facility can access care and treatment in the Emergency Department in a timely manner. A written pathway and flow diagram has been developed for staff.

Action Taken (AI summary) The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.

Action Taken (AI summary) Following an investigation, the Welsh Ambulance Services NHS Trust addressed failings by an individual staff member and provided additional education and support to call takers involved in the incident; the individual is being managed in line with Trust policies.

Action Taken (AI summary) The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on the ward via referral from a Consultant Psychiatrist or nursing staff.

Action Taken (AI summary) The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure. The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure.

Action Taken (AI summary) Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care plans for patients at risk of falls, daily auditing of nursing documentation will be carried out, and Multidisciplinary Team meetings on Ward 9F have been changed to earlier in the day.

Action Taken (AI summary) Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need for disciplinary action for breaches, greater written documentation, and are undertaking measures on a continual improvement basis.

Action Taken (AI summary) • All staff were briefed on the referral process to ensure full understanding, and learning from the joint investigation was shared. • The Trust met with East Lancashire Teaching Hospitals NHS Trust to explore in detail how to improve the referral process. • The Trust is looking to utilise the CRISP board within the Emergency Department to record referrals made to specialist teams.

Action Taken (AI summary) Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and stock control.

Action Taken (AI summary) The trust implemented three new policies and a chart for unfractionated heparin administration. The guidelines now state that if the APTTR at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.

Action Taken (AI summary) Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.

Action Taken (AI summary) All patients prescribed anti-psychotic medication will receive a routine annual ECG as part of their care; the Lead Pharmacist will sample audit this by 31 January 2016. Training will be provided to the Nursing team regarding medicines that should indicate a referral for an ECG, and the issue of anti-psychotic medication and extended QT intervals will be included in HMP Long Lartin GP supervision session and the Mental Health MDT meeting.