2016

Action Planned (AI summary) The Royal College of Radiologists will make its Fellows and members aware of the British Thoracic Society Pleural Disease Guidelines 2010. Following concerns about admitting acutely unwell patients without HDU/ITU facilities, BMI Mount Alvernia Hospital updated its admission policy to ensure all patients meet admission criteria. They also introduced mandatory training details for consultants and conduct monthly audits of consultant input into medical records.

Action Planned (AI summary) Stockport NHS Trust is installing an electronic patient record system (EPR) called 'TrakCare' with full roll out expected in 2017. In the meantime they will continue monthly 'live' spot audits of inpatient records to improve written records and communication.

Action Planned (AI summary) The Trust has undertaken several actions to address radiology reporting delays, including offering overtime to consultants, supporting undergraduate radiographer training, maximizing advanced practitioner skills, employing locums, introducing advice and guidance for GPs, and workforce planning. Voice recognition technology has been rolled out across all radiology staff. The Department of Health is increasing clinical radiology training posts by 32 in 2016 and is reviewing specialty intakes from 2017 onwards, taking into account the Urgent and Emergency Care Review. NHS England is implementing urgent and emergency care networks.

Action Planned (AI summary) Highways England commissioned a review of preventative measures for suicides on the Orwell Bridge and are reviewing the effectiveness of the telephones located at either end of the bridge, and will implement changes at the earliest opportunity. They are not intending to take further action regarding toe holds on the outer face of the bridge.

Action Planned (AI summary) Following the report, Welsh Government facilitated a meeting between all Health Boards mental health managers to discuss using Welsh NHS beds whenever possible. They also highlighted the existing requirement for care coordinators and treatment plans for all patients in Wales receiving secondary mental health services, even when placed 'out of area'. Powys Teaching Health Board is working to repatriate Mental Health Services for direct delivery, expecting to treat more patients within Powys and reduce out-of-county placements. Kent and Medway NHS Trust revised its 'Unable to Contact' Protocol, launched it at the Acute Leadership Forum, and cascaded training to CRHT teams. The new Protocol is being piloted in CRHTs trust wide for 3 months to ensure the changes are robust and workable.

Action Planned (AI summary) The Department of Transport commissioned the Northern Trans Pennine study, covering the A66 and A69 and the Chancellor announced in the 2016 Budget his commitment to upgrade the A66 and A69. Safety improvements at specific locations on the A66 are to be delivered this financial year.

Action Planned (AI summary) The Welsh Government will issue an addendum to Health Building Note 35, highlighting the requirement for ligature-free design in both new and existing acute mental health unit facilities. They have also requested a formal review of HBN 35 by NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES). The Health Board will repeat ligature audits across mental health and learning disability in-patient units and submit prioritised recommendations for consideration by the 2016/17 Capital programme regarding replacement, repair or adaptation of windows. In the meantime, inpatient areas will continue to be subject to regular environmental risk assessment.

Action Planned (AI summary) The company will be submitting an application to the MHRA to update the labelling of several E45 products to include guidance on potential flammability. The warning to be added to the product labelling is: "If using large quantities, regularly change clothing, bedding or dressings impregnated with the product and keep away from fire as may pose a fire hazard". CFOA has circulated the report to Chief Fire Officers/Chief Executives and other practitioners in the fire and rescue services and Chief Fire Officers/Chief Executives will ensure that the information and details contained within your report are shared with the appropriate staff. The MHRA included an article in Drug Safety Update on paraffin-based skin emollients and fire risk, reminding healthcare professionals to advise patients on the risks and to change clothing and bedding regularly. NHS Improvement have informed the editors of the BNF that the risk also applies to less concentrated aqueous based paraffin containing products, and the BNF will in future include a revised warning that will inform healthcare professionals of the risk applying to all paraffin containing products. NHS Improvement will communicate this risk to the Medication Safety Officers (MSOs) network so the risk can be appropriately communicated and addressed within their organisations. NHS Improvement have also asked the Care Quality Commission, the Royal College of Nursing, and networks within the care home sector to communicate the risk via suitable newsletter and bulletin articles.

Action Planned (AI summary) The Trust will include a statement within the newsletter sent to GPs within the Trust's catchment area reminding them of 24-hour access to the Trust's pathology department. They will also be sending a letter to each of their three local CCGs requesting that this information is passed on to all registered care homes in their area. The CCG's Quality Committee has undertaken an in-depth analysis of the issues relating to nursing and residential care home quality, which will lead to changes in the way they commission and assure quality of services. They are at the final stages of developing a nursing home Primary Care Standard, recruiting a specialist dietician and the CHC team will raise concerns should they find poor documentation either from the nursing/residential home andlor poorly documented communication between general practitioner and care home staff. The practice has drafted a policy regarding telephone advice to nursing homes, and will audit responses to nursing home phone requests 6 months after implementation. They are waiting for BMA clarity on multi-disciplinary notes before committing to a stance, but are in agreement with the nursing home regarding contemporaneous notes.