2017

Noted (AI summary) The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information. Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.

Noted (AI summary) The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to determine the college's next steps. The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal College of Psychiatrists will consider the concerns and determine if more can be done.

Noted (AI summary) The Department of Health acknowledges the concerns and notes that the Royal College of Surgeons, the Royal College of Anaesthetists and the Nursing and Midwifery Council have replied to the report, as well as actions taken by SBNS and BASS and the Royal College of Anaesthetists. The Royal College of Surgeons shared the coroner's letter with the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS), who jointly prepared a letter to their members highlighting learning points. The SBNS and BASS recommended disclosing the risk of major vascular injury during consent, regular education on vascular injury risks, and established protocols for urgent vascular imaging and acute vascular services. The NMC is undertaking a wholesale review of their education standards, including pre-registration standards, which will include specific standards relating to patient assessment and management of patient deterioration. They are undertaking a public consultation on the draft standards. Woodland Hospital has reflected on the case at Clinical Governance Committee, discussed it at theatre team meetings, and will include it at a reflective learning session. A bed side Haemocue machine has been installed in recovery, and emergency skills drills have been undertaken in recovery.

Noted (AI summary) The MHRA reviewed the SUSAR report and determined that the symptoms were in line with the known safety profile for nivolumab, and no further action is required for participants in nivolumab clinical trials. They also stated that conflict of interest lies outside the remit of MHRA for clinical trials.

Noted (AI summary) The Department of Health acknowledges the concerns and outlines the actions taken by other bodies (NHS England, NHS Improvement, CQC) but does not commit to any specific actions by the Department itself, beyond requiring trusts to publish data on avoidable deaths. The hospital acknowledges the concerns and outlines several actions, including reviewing the previous non-compliance with internal guidelines, but no specific actions are identified as already completed. The CQC response notes that the trust has already included items on its action plan to improve multidisciplinary communication and documentation and will monitor progress. The trust has also put forward a business case for a CT scanner on site, which the CQC will monitor.

Noted (AI summary) The surgery will raise the case as a discussion point in a practice meeting, make all doctors aware of self-referrals, and produce posters to put up in the waiting room to encourage patients with a family history of AA to self-refer for screening, also mentioning this fact in their PPG newsletter. The Trust has reviewed the process for rejecting imaging referrals and is strengthening the relevant guideline to include a clear statement of why the rejection was made. A new system has been implemented for redirecting imaging referrals sent to the incorrect team, and communication has been sent to GPs informing them how to refer into the Screening Programme. The CCG has enclosed the signed final report regarding the Serious Incident investigation into this case and confirmed that they have contacted the family to share the report.