2017

Action Planned (AI summary) Following a review, the police force will implement eight recommendations including reviewing and amending the Sudden Death Policy, preventing closure of the STORM log until investigation completion, and recording all raised actions numerically.

Action Planned (AI summary) Ofsted will consider giving more focus to protecting pupils and staff from violent attack as part of its review of the inspection framework for education inspections which is expected to be in place for September 2019; the Safeguarding Group has been made aware of the coroner's concerns and these will be taken into account in future reviews.

Action Planned (AI summary) The JCVI is currently reviewing its advice on varicella vaccination and will consider including children with Down’s syndrome in the list of high-risk groups during meetings in 2018.

Action Planned (AI summary) The RCoA, AAGBI and DAS will publish articles and highlight the importance of capnography in the Safe Anaesthesia Liaison Group's Patient Safety Update, Anaesthesia News and the DAS newsletter. The RCoA's Simulation Working Group will consider creating guidance on crisis simulation for operating theatre teams. North West Anglia NHS Foundation Trust is planning simulation training for anaesthetists, commissioning human factors training, and undertaking a SCORE cultural survey, with a timescale for completion by the end of March 2018. Since June 2016, many substantive appointments have been made to the cadre of Consultant Anaesthetists at Hinchingbrooke Hospital. NHS Improvement added 'undetected oesophageal intubation' to their Never Event Framework in February 2018, and is developing national guidance in collaboration with relevant organisations. The RCoA's CPD includes training on perioperative emergencies and human factors.

Action Planned (AI summary) RLSS UK will raise swimming pool safety matters at the CIMSPA annual conference, which will host the launch of the HSE's revised guidance, Managing Health and Safety in Swimming Pools (HSG 179). The RLSS UK, CIMSPA and ukactive are committed to providing a summary of the changes and reminders about lifeguard vigilance.

Action Planned (AI summary) Heatherwood Court Hospital will review and update its Levels of Observation Policy and current enhanced observation recording documentation. They will introduce amended documentation for a 2-week trial and update the current training package to include video and exemplar copies of completed documentation. Healthcare Inspectorate Wales (HIW) completed an inspection of Heatherwood Court and raised concerns about observation of patients. In response, Heatherwood Court reviewed training and amended observation recording sheets. The Welsh government sent copies of the Code of Practice on the Mental Health Act to Heatherwood Court and all units managed by Ludlow Street Healthcare.

Action Planned (AI summary) The Trust is engaged in a program to improve record-keeping, including risk assessments and care plans, with active monitoring at all levels. They are also working with business change and training specialists to develop staff use of the Lorenzo electronic patient record system and with system suppliers to improve its performance.