2019

Action Taken (AI summary) The medical centre has implemented a regular search of the clinical system to identify patients taking regular opiate analgesia or Pregabalin with a past history of drug misuse and are contacting those patients to ensure an up to date record of their current illicit drug use.

Action Taken (AI summary) The Home Treatment Team Operational Procedure has been revised and approved, to ensure that it fully corresponds with the safeguards for fully assessed and initially assessed patients waiting for a bed.

Action Taken (AI summary) The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust and NHS Professionals to address referral delays and ensure prompt referrals in the future. They have also referred concerns about the HCA to the Care Quality Commission. NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to manage complaints and investigations. They also use a Complaints and Incidents Management System (CIMS) feedback form to address concerns raised by Client Trusts.

Action Taken (AI summary) HMP Woodhill updated contingency plans to expedite emergency vehicle access, including immediate contact with ambulance services, staff reporting to the prison to await the ambulance, and training for Operational Support Grades (OSGs). All Custodial Managers will have had the opportunity to test these new arrangements. CNWL NHS Trust has implemented new AEDs with data cards, introduced an Offender Care Resuscitation Review Group, and commissioned an external review of emergency response practices. A 'Train the Trainer' course was also completed to enable regular local emergency response training.

Action Taken (AI summary) Following the incident, URBN UK replaced the broken lock, removed moveable items from beyond the gate, instructed staff not to access the area, installed signage, replaced scaffolding with high railings, infilled voids with steel plates, installed a pulley system, and trained staff in harness use.

Action Taken (AI summary) The health board detailed actions taken in response to the Adult Protection General Protection Plan, addressing concerns 1-5, and confirmed circulation of MHRA guidance on safe use of bed rails to care home providers. They also outlined actions taken to improve clarity and transparency in GP interactions, documentation, discussions with patients, and DNACPR procedures, as well as reviewing DOLs for residents using bed rails.

Action Taken (AI summary) Lancashire Constabulary is leading a multi-agency review of the MARAC process, testing new models for responding to cases in 'live-time', and is addressing the wider family impact of domestic abuse. They have also delivered DA and HBV/FMFGM training to probation officers and implemented 'Operation Encompass' with DA training to school staff.

Action Taken (AI summary) South Western Railway has updated its on-board procedure for medical emergencies, including the Guard, Driver, Control Centre and Signallers, to optimize the time taken to determine the best station for ambulance services to assist. They have also updated the Driver's section of the Booklet to advise passengers about the limitations of the Pass-Com system. The British Heart Foundation has invested over £2m in its 'Nation of Lifesavers' programme, training over 5.5m people in CPR, and is funding CPR kits in over 85% of UK secondary schools. They are also investing over £4.5m in developing 'The Circuit,' a national defibrillator network connected to ambulance services.