2017

Action Planned (AI summary) ADS has re-negotiated with Pennine Care NHS Trust for clinical advice and supervision, and has commissioned Applied Suicide Intervention Skills Training (ASIST) for shared care staff.

Action Planned (AI summary) The Trust has undertaken an audit of record keeping, is developing a clinical records keeping video, and is providing human factors training; it will continue to audit patients unexpectedly brought to intensive care.

Action Planned (AI summary) The Trust has updated the Root Cause Analysis investigation action plan and will implement electronic observations trust-wide by May 2018 with automatic escalation to doctors. The Royal College of Surgeons completed a review of Dr. Marshall's care; the Trust will review the report, consider recommendations, and develop an action plan.

Action Planned (AI summary) The Trust intends to improve communications by introducing a process whereby Clinical Hub staff within EOC are able to make direct radio contact with police on scene; the Trust is discussing implementation with police forces. A review of current processes and communications between agencies is within the scope of the Sheffield Crisis Care Concordat.

Action Planned (AI summary) The care centre has created a corrective action plan to optimise resources by changing work patterns to reduce risk and increase safety. A review of the incident showed that changes need to be made to optimise and make best use of the resources.

Action Planned (AI summary) The Somerset Safeguarding Children Board is proposing to commission a thematic learning review to establish whether there are any specific issues that need to be addressed by organisations in Somerset. The CCG notes that there is now a single point of access (SPA) for CAMHS, outlining improved access. They are working with the Trust to ensure the sharing of documented 'safety plans' with patients and their families becomes part of routine practice for people with identified immediate risks. The multi-agency Child Death Overview Panel (CDOP) made recommendations including clearer communication of crisis plans with parents, earlier school liaison, easier CAMHS access to senior medical staff, and more sensitive SUI report phrasing. Sofia's death will be the subject of a Learning Review. The Trust has commenced training staff in national investigation tools and techniques with a cohort of trained investigators to be in place by the end of 2017. Bereaved families are being asked to meet and contribute to the learning by sharing their own experiences.

Action Planned (AI summary) Highways England plans to implement a drainage scheme starting in February 2018, including silt removal, pipe repairs, and additional drainage installation. They will also make alterations to the vehicle restraint barrier, pending agreement with a third party, aiming for completion by June 2018.

Action Planned (AI summary) Homerton University Hospital is implementing electronic referrals via e-RS for GPs by April 2018. They are taking actions to mitigate risks related to dentists not being able to use the system, as they cannot fix the issues locally. Kindandental has applied for an NHS net email address and plans to use it for electronic referrals within two weeks of access and training. They also plan to build functionality into their system to send referrals via other email services with patient consent, and reviewed/updated their referral pathways and associated checklist to ensure thorough referral processes, emphasizing verification of patient details.

Action Planned (AI summary) HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training.