2017

Noted (AI summary) TfL states they have well established methods to determine grip levels across the Transport for London's Road Network, including cycle superhighways, and implement a comprehensive skid resistance policy. They will be raising the issue of differential skid resistance across a lane with the UK Roads Board.

Noted (AI summary) The practice has sent personal letters to patients on repeat prescriptions for Benzodiazepines asking them to contact the practice for a medication review. The practice has made a commitment not to add (or continue repeat prescriptions from patients registering from other practices) Benzodiazepines to a repeat prescription if not already on repeat. The GP has referred themselves to the Deputy Medical Director for appraisal. The Royal College of General Practitioners provides context on its role, describes its training and membership offerings, and references existing guidance on benzodiazepine prescribing. It supports a joint consensus statement on action needed to tackle addiction to medicines. NHS England will ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief pharmacists in mental health trusts in England to raise awareness of the risks associated with benzodiazepine prescribing and withdrawal. Devon LMC will remind practices about the review of patients receiving short-acting Benzodiazepines via its electronic newsletter and will make the information available on its website.

Noted (AI summary) Sussex Partnership NHS Foundation Trust explains that they were not chosen by Brighton and Hove City Council to continue providing local substance misuse services and encourages the coroner to write to the council with concerns. They ensured Public Health England guidance was provided to relevant directors and managers. Brighton & Hove City Council's Public Health department, as commissioner for adult and substance misuse in-patient detoxification beds, explains the history of service provision, noting the decision to work with Cranstoun in London after Sussex Partnership NHS Foundation Trust terminated their local service. They provide data on dual diagnosis prevalence. Brighton and Hove CCG highlights existing measures like a Dual Diagnosis integrated model, co-located DD workers, accommodation with support, and a Rough Sleepers project. Service user feedback is regularly reviewed, and Drug Related Death audits are undertaken.

Noted (AI summary) The Department for Transport expresses condolences but states there are no current plans to limit engine capacity for young drivers. They highlight existing road safety initiatives and commissioned research on measures to improve young driver safety.

Noted (AI summary) JRCALC clarifies it is not responsible for setting health education requirements for paramedics. AACE and NASMeD will provide the full response to the PFD. The Association of Ambulance Chief Executives will request that JRCALC review the UK ambulance service clinical practice guidelines for the management of renal patients, specifically in relation to fistula bleeds. They have also written to the Vascular Access Society of Britain & Ireland to seek specialist advice.

Noted (AI summary) Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and primary healthcare, and will discuss collaboration with CSSIW regarding communication between health services and care homes. Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients registering from nursing/care homes; they will audit the process in 6 months. Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the GP, and a specific proforma completed on discharge for patients from care homes; they investigated and addressed an incorrectly addressed discharge summary, noting improvements in access to the Welsh Clinical Portal. CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers relevant elements of care, and is satisfied that no additional policy change is required.

Noted (AI summary) CSSIW cannot impose a blanket ban on care workers assisting service users to smoke, but will issue general guidance to care providers on assessing and mitigating health and fire risks associated with smoking, and exploring alternatives. CQC acknowledges the concerns, notes the service falls under CSSIW jurisdiction, and states their current inspection process covers governance systems, supervision, and accident/incident reviews, but does not support a blanket prohibition on assisting with smoking, preferring a case-by-case risk assessment.