2017

Noted (AI summary) The response explains that AJ Ways fits sensor strips or protective screens to chairs only upon request, and that the user instruction booklet highlights potential entrapment risks and user suitability. It also clarifies that the entrapment occurred in an area not covered by sensors and that they are a small manufacturer.

Noted (AI summary) The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information. Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.

Noted (AI summary) The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to determine the college's next steps. The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal College of Psychiatrists will consider the concerns and determine if more can be done.

Noted (AI summary) The Department of Health acknowledges the concerns and notes that the Royal College of Surgeons, the Royal College of Anaesthetists and the Nursing and Midwifery Council have replied to the report, as well as actions taken by SBNS and BASS and the Royal College of Anaesthetists. The Royal College of Surgeons shared the coroner's letter with the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS), who jointly prepared a letter to their members highlighting learning points. The SBNS and BASS recommended disclosing the risk of major vascular injury during consent, regular education on vascular injury risks, and established protocols for urgent vascular imaging and acute vascular services. The NMC is undertaking a wholesale review of their education standards, including pre-registration standards, which will include specific standards relating to patient assessment and management of patient deterioration. They are undertaking a public consultation on the draft standards. Woodland Hospital has reflected on the case at Clinical Governance Committee, discussed it at theatre team meetings, and will include it at a reflective learning session. A bed side Haemocue machine has been installed in recovery, and emergency skills drills have been undertaken in recovery.