2017

Action Planned (AI summary) The prison Mental Health services are using more specific language than "ligature" to describe observations, discussed in team meetings. The Trust will work with partners to agree and promote a guidance document within the NE prison cluster.

Action Planned (AI summary) Cheshire East Council has programmed works to remove and relocate a road sign situated in the footway and re-kerb a length of the road to provide a higher consistent kerb height. The Road Safety Team will also conduct a complete Safety Assessment of the carriageway regarding the provision of a cycleway.

Action Planned (AI summary) The Trust's Head of Nursing reviewed the concerns and will share the learning with staff in Respiratory Medicine through sessions focusing on discharge procedures, responding to changes in patient NEWS scores, and appropriate documentation. Mr Pollard's care will be explored again at the next Respiratory Morbidity and Mortality Meeting and raised at the Trust-wide Deteriorating Patient Steering Group meeting.

Action Planned (AI summary) A new protocol for the transfer of patients requiring life-saving surgery has been written and shared with relevant stakeholders. The protocol has been published online and all critical care units in the country have been contacted. Sheffield Teaching Hospitals NHS is finalising and communicating a local protocol for the admission of patients requiring emergency neurosurgical procedures, based on SBNS guidelines. This will be shared with trusts within their neurosurgery catchment area. NHS England sought assurance from Specialised Neurosurgical Centres and referring hospitals that protocols are in place to ensure patients requiring life-saving surgical intervention will be referred regardless of critical care bed availability. Neuroscience Centres confirmed that protocols are in place and adhered to, and the Society of British Neurological Surgeons re-circulated guidelines on patient transfer.

Action Planned (AI summary) The Department of Health acknowledges the need for consistent implementation of patient safety requirements for nasogastric tubes. They are considering the evidence and economic implications of routine pH testing and will consider mandating it if the evidence supports it. The DH also highlights NIHR funding for a location-indicating naso-gastric tube being developed by the University of Hull. The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 and reported to the public Board meeting in March 2017.

Action Planned (AI summary) The Department of Health acknowledges concerns about nasogastric tube misplacement and refers to ongoing work, including an NIHR-funded project at the University of Hull to develop a location-indicating NGT. The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 and reported to the public Board meeting in March 2017.

Action Planned (AI summary) The Health Board is implementing an Unscheduled Care Plan in 2017/18 to improve waiting times for hospital admissions and reduce bed occupancy. The plan includes targets for each section and will be overseen by a Health Board-wide Transformation Group, with progress monitored monthly and by Welsh Government.

Action Planned (AI summary) The Trust states that it has adequate neonatal facilities but acknowledges that the Neonatal Unit requires modernisation. The Trust Board approved a redevelopment plan including the NICU and the Strategic Outline Case is awaiting consideration.

Action Planned (AI summary) The RCOG will consider the coroner's recommendations regarding bacteriological examination and antibiotic treatment of discoloured amniotic fluid when revising their Green-top guideline. They will also consider adding a prominent notice to their website encouraging doctors to consider these actions.