2018

Action Taken (AI summary) South East Coast Ambulance Service NHS Trust is recruiting additional crew members and purchasing new and second-hand ambulances. They have provided enhanced training to Support Call Takers, introduced a new Patient Welfare Procedure, and changed the procedure for standing down ambulances.

Action Taken (AI summary) The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce prisoner access to non-prescribed medication have been introduced including assigning responsibility for medication queue management to one person, marking the dispensary floor for security and privacy, using CCTV, providing staff with attendee lists, and implementing a medication management practice where certain drugs are dispensed by healthcare. Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the risks of NPS. They state a commitment to implementing lessons across Care UK's services.

Action Taken (AI summary) The Trust has implemented an e-observations system on adult in-patient wards that automatically calculates NEWS, prompts observations, and escalates concerns. They are also providing training and education on "revised escalation" and will continue this as they switch to NEWS2 in October 2018.

Action Taken (AI summary) Canary Wharf Group PLC has increased security patrols and implemented a stricter call-out procedure for suspected intruders. They also replaced the torches used by security guards with more powerful flashlights.

Action Taken (AI summary) Network Rail has trained over 20,000 railway staff to intervene with people who may be at risk of suicide, funded and implemented a team of eight patrollers in the Thameslink area to conduct suicide prevention patrols, and engaged with the local authority to discuss community-based suicide prevention measures. They also highlight existing fencing and risk assessment protocols.

Action Taken (AI summary) The Commissioning Alliance reports that changes have been made to IT systems to flag up early ordering of scripts, arrangements have been made to ensure staff have time to manage prescription requests, and access to online requests for repeat prescriptions of opiates and other drugs of dependency have been removed. They are also providing ongoing support around embedding a High Risk Drug review protocol. North Laine Medical Centre has updated its repeat prescribing policy, including tighter controls on controlled drug prescriptions, changes to computer settings to flag early script requests, and new procedures for uncollected prescriptions. They have also re-circulated existing guidance. Brighton and Sussex University Hospitals has fed back concerns about discharge summaries to the Clinical Director for Emergency and Acute Medicine and the Consultant and Governance Lead for Emergency Medicine, who have discussed the issues with medical staff. They also plan to implement systems within the next 12 months to allow discharge letters and summaries to be sent electronically.

Action Taken (AI summary) Warwickshire Police has updated its working practice guidance to require call handlers to follow up a transfer of a missing person report to another force with a telephone call to confirm receipt of information. They have also re-circulated College of Policing guidance on ownership of missing persons.

Action Taken (AI summary) The London Ambulance Service reports that the Emergency Medical Dispatcher involved in the incident has been subject to performance management and given additional training. They have undertaken a review of staff rotas, and are undertaking a recruitment programme for the Clinical Hub. They also highlight existing access to patient medical history and involvement in a national review of ambulance response times.

Action Taken (AI summary) The Trust has revised its procedures and processes to ensure that all patients with hyponatraemia will have a clear treatment plan to correct their sodium in line with recognised guidance. The case was also presented at the Epsom Hospital Grand Round meeting and circulated to all consultants within the Trust.