2019

Action Taken (AI summary) Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation and patient safety.

Action Taken (AI summary) The TRU revised policies and procedures for critical decision-making, multidisciplinary team communications, mental capacity assessments, care coordination, communication with family and statutory services, and aftercare/discharge planning. The Responsible Clinician made a referral to the General Medical Council and undertook further professional development.

Action Taken (AI summary) The Trust reviewed decision-making between teams, reinforced documentation of significant decisions, reiterated consultant support availability to junior doctors, and instituted a rota for senior pharmacist support out-of-hours.

Action Taken (AI summary) The Trust implemented pre-alert guidance in Dec 2018 developed with clinical directors and the Royal College of Emergency Medicine, reinforced sepsis guidelines in mandatory training, and is designing an escalation process for ambulance crews when concerns aren't addressed in the Emergency Department.

Action Taken (AI summary) The organisation has conducted team meetings and supervision sessions and is introducing a specific audit relating to the handover process from 29 January 2020. They have reviewed and updated robust systems and ensured they are in place.

Action Taken (AI summary) Windmill Manor has created a new Agency Folder with key policies. Barchester is rolling out a modified induction checklist, pocket guide and poster across all homes by the end of February 2020, and compliance will be checked via the Quality Governance Framework.

Action Taken (AI summary) Stockport CCG reports that Fernlea Nursing Home now uses photographs to track the progress of pressure sores, and referrals to the Tissue Viability Team are escalated if not actioned within 2 working days. A "React to Red" training programme has been developed and rolled out across the Stockport Care Home community. The CQC inspected Fernlea Care Home and found the service had failed to send a statutory notification regarding Mr. Ward's pressure ulcer. They will consider further enforcement action regarding this and will provide a copy of the inspection report to HM Coroner. Fernlea Care Home has arranged for all Registered Nurses to undertake third party wound management refresher training and has extended "React to Red" training to 87% of the care team. They have adopted the NHS wound management document, changed referral processes to TVNs, and will notify the GP of all TVN referrals.

Action Taken (AI summary) Leeds and York NHS Trust has created guidance for staff on assessing risk in referrals, ensuring consideration of self-harm/suicide risk. They will update the referral form and information leaflet, and implement a standard referral receipt letter providing details of relevant crisis support services.

Action Taken (AI summary) The Trust disputes that lessons haven't been learned regarding NEWS, citing the implementation of electronic patient observations (Patientrack) in all adult and paediatric inpatient areas since July 2019, with Maternity and ED to follow. All Radiologists have been reminded to look at the SMA, the protocol has changed to enable better visualization and overnight scans are reviewed by a Consultant the following morning.

Action Taken (AI summary) The RPS highlights existing guidance for pharmacy teams covering prescription requests to GPs, published in 2015 and available on their website. They also updated and published a Prescribing Competency Framework in 2017 covering safe prescribing of repeat medicines.

Action Taken (AI summary) The Ministry of Defence outlines changes made to the Army recruitment process, including revised medical screening for Sickle Cell Trait, updated risk management processes for physical training, and clarified roles and responsibilities for training staff. They also removed previous versions of AGAI Vol 1 Ch 7 from use and circulation. The Ministry of Defence reports on actions taken, including improvements to sickle cell trait screening, mandating training for staff on exertional collapse, and implementing a joint clinical policy for exertional collapse. They also ensure Defence Medic training incorporates exertional collapse scenarios.