2016

Action Planned (AI summary) Greater Manchester will raise concerns about volumes/strengths of prescribed controlled drugs and provide guidance to prescribers, as well as examine its reporting system to identify high-volume prescribers. They will highlight prescribing volumes in the national Care Quality Commission "Controlled Drugs Vigilance Newsletter" and use local newsletters, with some CCGs already working with practices to reduce high doses. The Home Office notes the concerns and states information from the investigation has been added to the Yellow Card Scheme to monitor substances suspected of being misused. The Home Secretary has commissioned the ACMD to explore potential medical and social harms arising from the illicit supply of medicines.

Action Planned (AI summary) Staffordshire County Council proposes to not reinstate a 'Keep Clear' marking and install a short section of guardrail at the junction of Ball Haye Street and Fountain Street in Leek. These measures are proposed to be funded from the 2016/17 financial year Capital Programme.

Action Planned (AI summary) The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion of the issues with the staff at Grosvenor Park Care Home. Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate details associated with a diagnosis of osteoporosis and increased risk of fracture, and now refers residents to the Community Matron for review after low impact falls.

Action Planned (AI summary) Stockport Metropolitan Borough Council plans to make a bid to the Greater Manchester Casualty Reduction Partnership for funding to install a central barrier on Crookilley Way. They are also planning a review of the speed limit on that road.

Action Planned (AI summary) The Pharmacy department at Barts Health NHS Trust is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity, and a 'share the learning' bulletin. Newham University Hospital is planning to review Serious Untoward Incidents reported from 2013 to date to identify if there are any opiate related SUIs and is retraining all nursing staff.

Action Planned (AI summary) The practice agreed to encourage sharing appropriate information with relatives and carers, always discussing this with the patient, and has informed the NHS Northern, Eastern and Western Clinical Commissioning Group of the issues raised for wider sharing.

Action Planned (AI summary) The Trust has developed an 'In-patient leave agreement' and an 'In-patient leave checklist' to be completed before a patient goes on leave, with a pilot on older persons wards aiming for full introduction by the end of the month and quarterly audits starting in July 2016.

Action Planned (AI summary) The hospital will review the existing stock list of over-labelled and pre-packed medicines with the Accident and Emergency Department by 31 May 2016. They also plan to advertise the opening hours and process for obtaining medicines out of hours with the Accident and Emergency Department in April 2016.

Action Planned (AI summary) The FICM and ICS Joint Standards Committee are discussing how to monitor incident reports and publicise lessons learnt, and Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed.

Action Planned (AI summary) The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the importance of monitoring creatinine clearance is being reiterated to clinicians and pharmacists.

Action Planned (AI summary) The officers involved will shortly receive training on when and how to administer CPR, and all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR; all officers will be trained further as to the management of scenes following a RTC where a major injury is suspected.

Action Planned (AI summary) The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and consider other workforce diversity options if there are no applicants again.