2016

Action Planned (AI summary) The National Trust is investigating options for signage at Hells Mouth with the Cornwall Samaritans and anticipates installing signs on their land before Easter. They do not plan to plant vegetation due to practical concerns.

Action Planned (AI summary) The surgery will conduct a survey of visit requests by the home and seek feedback on how to improve the process. They have a lower threshold for home visit requests from this Home given that the information given on the telephone by carers may not reflect the true health needs of residents.

Action Planned (AI summary) Bednest has modified its cribs, sent modification kits to known purchasers, added additional labeling, ceased sales through retailers like NCT, and maintains information about the modification kit on their website. They continue to monitor second-hand sales and work with Trading Standards. The Department for Business Energy and Industrial Strategy will discuss with BSI how to ensure paediatric advice is fed into the revision of the standard for cribs and cradles and will engage with stakeholders to gather further intelligence on products such as these. They will also engage with RoSPA on whether there is a need to improve general guidance and raise consumer awareness surrounding the sleep environment.

Action Planned (AI summary) Birmingham City Council will develop and consult on road safety improvements along Grove Lane, with implementation planned for 2017/18 and aspiration for completion by July 2017.

Action Planned (AI summary) Allied Healthcare acknowledges the concerns and will perform a review of practices/policies/procedures relating to the use of slide sheets and update the Senior Coroner. They confirm that all of Allied Healthcare's training documents are currently being reviewed every two years or sooner, if guidelines change. RDASH held a meeting with District Nurses and their Line Managers to discuss the report. Training on pain management in patients with dementia and cognitive impairment is ongoing and will incorporate learning from the Regulation 28 report.

Action Planned (AI summary) For skydive students with non-standard body morphology, the BPA recommends a formal written risk assessment and special consideration for wind tunnel training, possibly with two instructors during AFF levels 4-7.

Action Planned (AI summary) The practice will liaise with care homes to get written confirmation when a patient changes GP, including consent and next of kin notification; future projects will include better advertisement; communication arriving at the old practice will be forwarded to the new practice; and a written policy will be created for changing patient care when a patient resides in a care home. In the future, project plans must outline roles and responsibilities, communications must be dated and documented, there must be a system for forwarding communications regarding patients, carehomes should have systems for tracking information shared with GP practices, and ELR CCG will require providers to keep a record of information received and discussed with residents. The practice will improve advertisement of changes with posters, require written signed documentation of conversations with patient or next of kin, and forward communication received by the donor practice to the receiving practice for six weeks.

Action Planned (AI summary) The RYA has refreshed the safety information pages on its website and will be highlighting this safety information to its members through various electronic communications and in the RYA's annual Safety Advisory Notice. The BMC will make climbers aware of the risks of dangerously low temperatures in coastal waters, including Cold Water Shock, in their guidance and will raise this with guidebook writers. They will also emphasize the importance of not deep water soloing alone and suggest climbers tell others of their plans and expected return time.

Action Planned (AI summary) South West Hampshire LIFT has reviewed the Transport Planning Consultancy report regarding proposed car parking improvement measures at Adelaide Health Centre. The Board has instructed such measures to be implemented, and will seek planning consent to progress the improvements at the earliest opportunity.

Action Planned (AI summary) Sherwood Forest Hospitals NHS Trust has determined that following referral of Mrs. S to the vascular team, a letter was sent to Mrs. Stokes on 15 July 2015. Following this case, patient contact information has been reviewed. Further to the investigations referred to, Mrs S’ case is to be discussed at the next vascular Morbidity and Mortality meeting at NUH. The legal team is to be made part of the Governance Directorate, with offices adjacent to enable a greater working relationship. The Radiology Department will review and modify its XXXX policy to take account of electronic reporting and a referrer acknowledgement system.

Action Planned (AI summary) North East London NHS Foundation Trust is undertaking a series of actions including sending FOI requests to other trusts, reviewing and updating S136 guidance and policy, creating a secure NHS net account for the S136 suite, and holding a board workshop to discuss SI investigations. They will also explore inviting the Senior Coroner to deliver a presentation. The Borough Mental Team has identified four areas for improvement: handover of patients between the police and 136 suite staff; filing and storage of 136 paperwork; supporting officers dealing with 136 incidents; and training. Changes to Form 434, a review meeting planned for early February and a video presentation with Mrs Persaud for training are planned.

Action Planned (AI summary) The trust intends to address the need for increased capacity to conduct basic out-of-hours patient reviews and is considering options to expand out-of-hours community provision as part of its service transformation process.

Action Planned (AI summary) Impact will survey all residential properties with staff on site by the end of March 2017 to identify window styles and sizes, and will commence removing fixed restrictors and replacing them with override-able restrictors in April 2017, completing by end-March 2018, prioritising based on risk and funding availability.