2016

Action Planned (AI summary) The CCG will assess with provider organizations whether the "Green Light" audit tool can be applied to community services to review access of mental health services to individuals with learning disabilities and identify needed adjustments; assessment and agreement will be completed in 2016/17 to inform quality improvement initiatives in 2017/18. The Seaton & Colyton Medical Practice will hold a formal Significant Event Audit Meeting to discuss the case and consider appropriate pathways for others in similar situations.

Action Planned (AI summary) East Midlands Ambulance Service (EMAS) has discussed the concerns within the Coroners Working Group and developed an action plan, reintroduced monthly meetings with hospitals and commissioners to improve ambulance turnaround, and increased available hours for ambulances and fast response vehicles by recruiting staff and realigning rosters. Hardwick CCG, on behalf of 22 CCGs across the East Midlands region, will undertake a jointly commissioned external strategic review focussing on capacity and demand with EMAS, with implementation over three years and have provided additional funding to EMAS to undertake further recruitment. NHS England notes that an external strategic review of capacity and demand will be undertaken and that the 2016/17 contract settlement also provided additional funding to EMAS in order to increase front-line staffing with the intention of improving ambulance response times. NHS Improvement is working with the East Midlands Ambulance Service NHS Trust to address resourcing issues and improve response times and highlights that in 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.

Action Planned (AI summary) The DfE intends to consult on a revised version of guidance on school transport in the autumn and will consider whether they should further clarify the description of the training that drivers and escorts should receive. The DfT will reinforce the importance of basic life support training for drivers through targeted communications and social media, and raise the profile of the issue with bus industry and local authority stakeholders.

Action Planned (AI summary) The Caravan Club will include a reminder of fire safety, specifically the need for smoke detectors, in their monthly members' magazine and other publications. Surrey Fire and Rescue Service, working with partners, has visited identified mobile home sites in Surrey, conducting fire safety visits and fitting smoke and carbon monoxide alarms. They are planning to continue to raise awareness and have brought the coroner's recommendation to the attention of all Chief Fire Officers in England and Wales.

Action Planned (AI summary) The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation of the gate to attend at the start of a call. They have also held meetings with senior prison staff to promote effective communication. Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a training plan to ensure most healthcare staff will be ILS trained by December 2016, with yearly refresher trainings. NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have been briefed to provide the prison gate location at the beginning of calls to the London Ambulance Service.