2017

Noted (AI summary) Coxbench Hall Residential Home asserts that they have clear and robust policies and procedures in place in relation to falls risk assessment and management, including a policy checklist for staff, accident report forms, and a Falls Audit form.

Noted (AI summary) NHS England will ensure that the NICE lead for the Abdominal Aortic Aneurysm guideline is aware of the coroner's concerns and will ensure the report is considered by the working group led by the National Clinical Director for Diagnostics. The RCGP agrees GPs are unlikely to be aware that a supra-renal aortic aneurysm should raise concerns about the possibility of a thoracic aortic aneurysm; they rely on secondary care reports for recommendations about findings. The Society of Radiographers will communicate to radiology services the need for sonographers to have clear processes for arranging onward referral.

Noted (AI summary) Network Rail confirms that the crossing was closed to members of the public on 26 September 2017 via temporary order granted by Walsall Local Authority and remains closed today. In 2016 enhancements were made including extending the crossing deck, installing low level solar lighting studs, and de-vegetation works. Walsall MBC are undertaking an urgent review of Network Rail's revised closure application and continue to provide assistance and guidance to Network Rail in the closure application process. As Walsall MBC is not the landowner, it has no authority to convert the crossing into a controlled crossing.

Noted (AI summary) Following the incident, the cardiomyopathy service now ensures that email correspondence with patients is added to the patient's health record. Trust-wide guidelines are being developed regarding email communication with patients. The Department of Health acknowledges the coroner's concerns, references existing GMC guidance on communication, and notes that Barts Health NHS Trust is addressing the issue. They state that concerns about individual clinicians should be raised with the GMC. The Trust is exploring current practice regarding email correspondence between clinicians and patients and will consider local guidance based on NHS England's Accessible Information Standard, pending national guidelines.

Noted (AI summary) The Department of Health outlines national initiatives for safer maternity care, including the Healthcare Safety Investigations Branch, and highlights existing NICE guidelines on intrapartum care. They note that Portsmouth Hospitals NHS Trust is implementing an action plan. The ambulance service has updated its SOP so that any Health Care Professional requesting an emergency/immediate inter-facility transfer will be asked "Do you require a Time Critical Transfer?" The policy regarding the use of standby points is also being updated.

Noted (AI summary) The council acknowledges the coroner's concerns but states that current training for sheltered housing staff is adequate for their roles, which do not include lifting residents who have fallen.