2019

Action Planned (AI summary) HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to staff as part of the prison’s monthly training provision.

Action Planned (AI summary) Hampshire Constabulary will mandate electronic self-learning packages on Prisoner Escort Records for Custody Officers and Detention Officers, review the content annually, and raise the issues in the Regulation 28 Notice at the next HM Courts and Tribunal Service working group meeting. CNWL NHS Trust details existing ACCT and SASH training, reception screening processes with standardized training being rolled out, twice-yearly care records audits, and staff supervision policies including discussion of care plans and risk assessments.

Action Planned (AI summary) Cornwall Council is developing a multiagency strategy (2019-23) to improve support for people with complex needs, including mental health and substance use issues. A task and finish project will review prevention services, domiciliary care, and supported housing, aiming to develop specialist supported housing and address gaps in service provision by April 2021.

Action Planned (AI summary) G4S now alerts its subcontractor UHS immediately of safeguarding concerns raised in Service Commission Forms from UKVI so that such cases can be raised with the Senior Safeguarding working group. Significant improvements have been made in relation to such cases, in particular, with the information conveyed by UKVI to G4S/UHS. Urban Housing Services has reviewed procedures and interactions with other agencies, including flagging incomplete safeguarding information with UKVI and G4S, directly notifying hospital visits to Attwood Green Medical Centre, updating out-of-hours guidance, and recording additional information in staff handover books. The Home Office is reviewing processes to ensure sufficient information is provided on Service Commission Forms, balancing this with data protection requirements. The Home Office will also share learning from this incident widely.

Action Planned (AI summary) NHSBT and BTS will write to SaBTO to formally advise them of this case and ask for a clear position on donor screening. BTS will discuss with their standards committee about any future guidance on Strongyloides infection in transplantation and NHSBT will write to Transplant Centre Directors to inform them anonymously of this case for awareness and include information on this infection as part of shared learning in NHSBTs Medical Bulletin and Cautionary Tales.

Action Planned (AI summary) NICE is undertaking a surveillance review of its head injury guideline (CG176) and the review is likely to conclude that an update is required to clarify that the guideline applies to indirect head injury. Shaw Healthcare has revised shift handover meetings, monitoring and management checks, GP/111 call procedures, information given to paramedics, and staff training, and has created a Falls Management Policy. They have increased training and awareness, and expect 90% of staff to have completed mandatory training at any one time.

Action Planned (AI summary) AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission.

Action Planned (AI summary) HMPPS is undertaking a robust recruitment drive and training programme to increase the number of qualified probation officers, with the expectation that current vacancies in the NPS will be filled by the end of 2021. Northumbria Police has sent force-wide bulletins to officers and staff informing them of the process for sharing information/intelligence with NPS when encountering a Category 2 Level 2 or 3 offender.