2016

Action Planned (AI summary) The Trust developed an Upper GI Bleed Transfer Policy for Bassetlaw Hospital after consultation between anaesthetic and medical teams. Staff will be made aware of the policy, and it will be ratified at the next Patient Safety Review Group meeting for wider dissemination.

Action Planned (AI summary) CLV has reviewed its risk assessment and measures in place to protect student safety relating to opening windows, provided training to CLV staff on mental health, put in place key communication channels to support staff, and developed a Residential Life Programme to foster a sense of community; a clear crisis management procedure has been introduced. The Department proposes to write to UUK and GuildHE by early July to ask them to ensure that HEIs are doing all they can to ensure the safety of students in such accommodation, including the points made concerning risk assessment and replacing window restrictors.

Action Planned (AI summary) The practice conducted audits of post and electronic communication review procedures and found them to be robust. They also met with Second Care Psychiatry colleagues to discuss the rejection process and performed a Significant Event Analysis on the patient's death; agreed to request DRSS to review procedures so all urgent mental health referrals that are rejected are telephoned through to the requesting GP as well as rejected through electronic communication. The organization will ensure staff that reject an urgent referral will contact the referrer directly to confirm the outcome. They will seek advice from the Local Medical Committee to ask how learning can be shared throughout the Primary Care arena and Secondary Care arena.

Action Planned (AI summary) The CAA is conducting a review of rules for flights under Instrument Flight Rules (IFR) outside controlled airspace, scheduled for completion by September 30, 2016. They will also renew Safety Notices and update AIP details by March 31, 2016, to provide enhanced information for pilots.

Action Planned (AI summary) • The CAA has instigated a thorough review of the rules applicable to flights performed under Instrument Flight Rules (IFR) outside controlled airspace through our Safety Review Committee. • This review will cover several of the issues raised in relation to this accident as well as the wider context of current and emerging practices and is scheduled to be completed by 30 September 2016. • Before taking off, the pilot of helicopter on private flight must be satisfied of a number of matters including that the flight can safely be made, the aircraft is in way fit for the intended flight

Action Planned (AI summary) The Adult Mental Health Management Team has assigned an action to Clinical Service Directors to formulate a standard plan to ensure that patients requesting second opinions have access to these and are not prematurely discharged if they advise that they are unable to attend their appointment. An RCA (Root Cause Analysis) was conducted to improve services and prevent similar issues.

Action Planned (AI summary) The Trust will strengthen communication between secretarial teams at Stepping Hill and Buxton to ensure radiology reports are available at both sites simultaneously. They will develop a standard operating procedure for sending all radiology reports from Buxton to Stepping Hill, regardless of urgency.

Action Planned (AI summary) The DWP believes its processes were followed correctly but will issue a reminder to all staff about guidance related to suicidal ideation. Following the incident, the involved crew undertook Reflective Learning, and a Clinical Update reinforcing the assessment of Capacity was published. A new Operational Management Structure was implemented, including Stakeholder Engagement Manager and Quality Assurance & Governance Manager roles, as well as funding for Mental Health Nurses in the control room. The Metropolitan Police will ensure that the future structure and resourcing model of Sapphire teams meets the demands of increased reporting levels and promotes a supportive working environment, and invest in training for first responders and investigators.

Action Planned (AI summary) The Trust is moving towards a Trust-wide electronic patient record (EPR) which should resolve issues around paper charts. In the meantime, a specialist "Task & Finish Group" is in place to further review the issue and develop an effective interim solution.

Action Planned (AI summary) The Department for Transport is working to improve direct and indirect vision for drivers, including international agreement to allow camera systems instead of mirrors, developing aerodynamic HGVs, and working with stakeholders on safer lorry designs.