2017

Action Planned (AI summary) Stockport NHS Trust acknowledges that high-resolution screens should ideally be used for viewing X-rays. They note that a NEWS implementation plan is being developed, independent of the delayed launch of the new electronic patient record (ePR).

Action Planned (AI summary) The University Health Board has reviewed the case and circumstances. They will ensure reception staff are aware if an appointment is with the Mental Health Team and direct accordingly and have reviewed the Disengagement Policy for Mental Health.

Action Planned (AI summary) Funding was allocated to implement recommendations from a 2016 road traffic collision study, including high friction surfacing, improved road marking and signage, which is currently out for consultation. The highways department immediately improved the white lining after a fatal collision in March 2017.

Action Planned (AI summary) The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR investigation. They have developed a 'Learning from Deaths' policy to respond to and learn from deaths of patients under their management. The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend to take. They are planning to inspect specific core services at BHRUT in the first part of 2018, including a 3-day in-depth inspection of the leadership and governance of the trust. NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next 6 months, focusing on treating patients with raised intracranial pressure and urging extreme caution in relation to the use of opiates. NHS England will also seek assurances from the Trust that they have addressed the concerns raised and will suggest an independent review of the case management.

Action Planned (AI summary) The Welsh Government is drafting regulations under the Renting Homes (Wales) Act 2016 that will place a legal duty on both social and private landlords to fit smoke and carbon monoxide alarms, with a consultation on the draft regulations underway.

Action Planned (AI summary) The department will ask the Building Regulations Advisory Committee to reconsider regulating stone fire surrounds and will alert registered installers to good practice guidance. Officials will also continue working with other agencies to keep guidance up to date.

Action Planned (AI summary) The Trust is piloting an Enhanced Care Standard Operating Procedure (SOP) with an Enhanced Care Risk Assessment Tool and criteria for observation levels, with a target ratification date of January 2018. It is also reviewing its Prevention and Management of Hospital-Based Falls Policy, with completion targeted for November 2017, linking it to the Enhanced Care SOP.

Action Planned (AI summary) HMP Winchester has taken on a temporary staff member to transcribe telephone calls, implemented a new protocol for information gathering, transcribed interview discs, and ordered a secure storage facility for documentation regarding any death in custody. The Head of Business Assurance is reviewing accounting systems and storage of internal investigation material. Carillion has contacted HMPPS and proposed a formal instruction for staff to undergo SASH training, is ready to issue a notice to site managers to make staff available, and suggested that HMPPS maintain a training record for Carillion staff. HMPPS has confirmed that all Carillion prisoner facing staff should be required to undergo training. The prison has issued notices to staff regarding emergency call bell response times and to prisoners about the misuse of call bells. The prison is also checking ECB response times daily and bidding for funding to upgrade the ECB system; nationally, a learning bulletin will be issued to staff on ECB importance and abuse in early 2018.

Action Planned (AI summary) The health board has incorporated actions into a formal plan with clear timescales and responsibilities for monitoring Mr Redmore's neurological state, acting upon NEWS observations, and undertaking observations in line with guidance. An advisory group will help deliver improvements.

Action Planned (AI summary) The Trust's safeguarding children training will include information about the Leaving Care Team, and bespoke training will be provided to ward managers and matrons for cascading to staff. The ward's operational policy will be reviewed to include contacting the Leaving Care Team upon admission of a young person previously in care, and staff will work with the young person to negotiate the involvement of their social worker.