2018

Action Taken (AI summary) Cwm Taf University Health Board has undertaken two audits of NEWS scores, identified the need for further education and training, and is monitoring improvement work via the quarterly quality report.

Action Taken (AI summary) FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither would add a further method of entry for emergency services.

Action Taken (AI summary) Dorset Council has already implemented several safety improvements, including installing a coloured band on a signpost, and has issued work orders to remove a redundant deflection arrow and relocate a cycle route sign, to be completed by the end of April 2018. Cycle safety training is regularly delivered to schools.

Action Taken (AI summary) Hampshire Hospitals NHS Foundation Trust has changed the default location on the relevant computer in the emergency department and educated clinicians on the importance of correctly recording the location of X-ray requests. St Francis Surgery has changed its procedure for requesting X-rays to electronic forms, and has reminded doctors to clearly record instructions to care staff in patient notes. Dr Fowler clarified the situation regarding the X-ray form in question.

Action Taken (AI summary) The Trust has already taken action by identifying that all relevant staff should undergo emergency scenario training and simulation, including human factors training for difficult airway management in emergency situations, and is planning further simulation training and development of a Patient Safety Faculty. The Department of Health notes that the Trust has an action plan in place that includes measures to ensure there are clear departmental guidelines based on the DAS's guidance, and to ensure that all relevant staff undergo emergency scenario training and simulation, including human factors training for difficult airway management in emergency situations; the Trust will also be developing emergency simulation training more generally and measures will be taken to strengthen leadership in emergency situations.

Action Taken (AI summary) The Trust completed a Root Cause Analysis (RCA) and has an action plan that confirms actions taken subsequent to the investigation, addressing concerns about contacting doctors, record keeping, and communication with family.

Action Taken (AI summary) The Trust has filled all substantive consultant appointments across inpatient areas within Manchester services and is developing proposals for forensic in-reach to support consultants and CMHTs; a rolling programme for all healthcare professionals promoting the importance of good record keeping is currently being delivered.

Action Taken (AI summary) The police force updated its missing person policy in September 2017, including new call handling guidance with mandatory risk level recording, and delivered related training to staff between January and March 2017. They also have a joint policy with Sussex Partnership NHS Foundation Trust regarding absent patients, which is currently under review with planned consultation with Safeguarding Boards. The Trust created a checklist of information needed by police during 999 calls about AWOL patients, which is being incorporated into the Trust's AWOL policy. Instructions for accessing CCTV have been positioned next to the computer, and staff have been trained on using the system.