2018

Action Planned (AI summary) The CAA will continue to drive forward the plan to ensure operators are `electronically conspicuous' which will help to reduce the incidence of such events. The MAC programme works closely and collaboratively with the UK Airprox Board, UK Flight Safety Committee, Military Aviation Authority and industry stakeholders to understand and assess risk and identify effective and collaborative mitigations.

Action Planned (AI summary) The evidence base regarding risk assessment for patients with bowel obstruction will be presented to clinicians at the departmental mortality and morbidity meeting, to remind them to ensure the surgical teams gave similarly considered the risk benefit for a nasogastric tube when booking cases for CEPOD (emergency) theatre.

Action Planned (AI summary) The FSA will be meeting with other government departments and organisations to discuss tackling food allergy issues, and welcomes the Coroner's contribution to these discussions; will also be placing more emphasis on reporting near misses and deaths from food allergy in the Practice Guidance and writing to local authorities to highlight lessons learned and reinforce expectations on good allergen management practices. The Trust has reviewed and updated its anaphylaxis draft protocol and included a referral form to inform Trading Standards of cases of anaphylactic reaction from commercial premises. The draft protocol will be reviewed and ratified at a meeting in March 2018. The FSA will set up a cross-government discussion to consider the reporting of non-fatal anaphylaxis, while Barnsley and Sheffield are exploring the development of local notification systems and considering ways to raise awareness among GPs.

Action Planned (AI summary) The Arboricultural Association will publish a summary of the events in a safety bulletin to its members and partner organisations by the end of February 2018 and in their quarterly magazine in June 2018, reminding arborists to use correct methods and techniques. The Forestry Commission will circulate the Arboricultural Association safety bulletin, review emergency procedures with in-house arborists, re-brief employees supervising arboricultural contracts, and update the training module for supervisors. The Arboriculture and Forestry Advisory Group (AFAG) will promulgate learning points from the incident via its committee members, and will ensure that these points are considered when specific guidance leaflets are next reviewed.