2018

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) 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) • Following notification of the collision, a Road Safety Engineer from the Traffic and Road Safety Group attended the site with the traffic Management Assistant from Warwickshire and West Mercia Police’s Road Safety Team. • At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken. • The County Council undertakes an annual review of all collision cluster sites and routes across the County to identify those with the worst collision records and where there is a pattern of causes which can be addressed by engineering measures.

Action Taken (AI summary) Southern Health NHS Foundation Trust revised the Risk Summary Section in its electronic patient record in January 2017, requiring all staff to input risk information according to national guidance. The Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures have been reviewed, and team managers have been instructed to ensure that staff communicate with GPs after triaging referrals and to regularly monitor that it is occurring.

Action Taken (AI summary) Estates & Management has provided further training to its teams on handling correspondence. Restrictors will be installed where necessary and letters have been sent to every leaseholder to carry out a survey, and amendments made to Health and Safety Risk Assessments to undertake annual inspections of apartments to check the restrictors are functioning correctly.

Action Taken (AI summary) Twinglobe Care Homes has implemented changes across its group of homes, including a Choking Risk Assessment, Choking and Aspiration Care Plan, Aspiration Guidance, Nutrition and Fluid Chart, Nutritional Profile, leaflet for relatives/visitors, poster, Deprivation of Liberty Screening Checklist, Mental Capacity Assessment Record, Best Interests Decision Form, Visiting and Visitors Policy, Meal and Mealtimes in Care Homes Policy, and Food bought in by Visitors Policy.

Action Taken (AI summary) The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken and ongoing as a result of the death, with oversight from the Trust Quality Delivery Group.

Action Taken (AI summary) Administrators now check both electronic patient information systems for referrals, and read-only access is available to administrators and team leads. A new referral inbox is used to share urgent risk information. The need to act on information has been reinforced within the CMHT, and learning has been disseminated to all CMHTs.

Action Taken (AI summary) The Dudley Group NHS Trust has revised guidelines for hypokalaemia management, publicised them on the intranet, and scheduled a presentation. Staff are working with a palliative care champion to complete in-house palliative care competencies covering communication with patients and families.