2017

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) A letter is being drafted to all General Practices in England highlighting high-risk cases when a phone call to the pharmacist should be made. A pilot scheme for Urgent Care services is due to be implemented across a controlled geographical area within the next month. Well has rolled out Best in Class Prescription Management across its stores, with field operations management team visits to check implementation and provide support. An improved reporting mechanism has been developed to record audit actions, and SOP14 has been updated.

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.