2019

Action Taken (AI summary) A new protocol clarifies physical observations for prisoners, and IDTS nurses now complete the National Early Warning Score (NEWS). Healthcare staff were reminded on February 13, 2019, to ensure appropriate observations are carried out during physical examinations.

Action Taken (AI summary) The MPS has updated investigator toolkits on mobile devices, provides safeguarding officers in BCU Operations Rooms, delivers mandatory week-long training to officers posted to MPUs, and increased staffing levels in the South Area MPU.

Action Taken (AI summary) Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended.

Action Taken (AI summary) NHS Improvement has shared information with the Royal United Hospital Bath NHS Foundation Trust about a mobility score, and has provided support for assessing its impact. They are also undertaking activities related to medication safety for older people.

Action Taken (AI summary) The Trust has already taken action to address the issues including emphasizing the need for staff to record explicit consent on information sharing forms and reviewing the Trust's consent to share information procedures. They have also clarified that the AWP switchboard can call 999 in an emergency and ensured that staff are aware of individualised communication options for service users.

Action Taken (AI summary) The Trust has reviewed the process for transfers between hospitals and is clarifying roles and responsibilities. They are also looking to 'RAG rate' all requests to transfer patients based on clinical need.

Action Taken (AI summary) The Matron for Theatres has confirmed that vital signs are continuously monitored in the recovery area post operatively and documented at set intervals. New signage has been introduced at the bedside to further support staff in recognizing which patients have a fluid balance chart in place; and a trust wide audit of fluid balance chart compliance has been added to the Trust Audit Programme for 2019/2020.

Action Taken (AI summary) The Trust has launched a revised programme of investigation training, including in-depth statement gathering and writing sessions, and implemented a checklist for investigation panel meetings to ensure key requirements are met. They also launched a Safer Mobility Collaborative aimed at reducing inpatient falls.

Action Taken (AI summary) The ambulance service uses the Advanced Medical Priority Dispatch System (AMPDS) and is actively recruiting staff to a newly created Clinical Hub to address call volume, with some staff already trained and operational. The Capacity Management and Escalation Plan is reviewed annually. The 111 service uses NHS Pathways software, updated twice yearly, with staff training covering sepsis, including a Distance Learning Pack with a formal assessment, and NICE Guidance on feverish illness. Clinicians receive sepsis risk stratification tools and are notified of a free online course on Sepsis in Primary Care.

Action Taken (AI summary) Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with medication, referencing actions for staff during weekdays and weekends; it was circulated to staff in December 2018. HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit to help staff meet the needs of those with Learning Disabilities and Challenges (LDC), and are opening a dedicated unit for prisoners with autism at HMP Wakefield.

Action Taken (AI summary) The CAA now requires calendar periods for engine overhaul for low-utilisation aircraft, reinforced the replacement lifespan of the YAK-52 engine with a new MPD, and will revise Safety Notice 2018/005 to emphasize calendar lives for safety harnesses and provide guidance on harness assessments; however, the CAA concluded it would not be appropriate to request the manufacturer to specify a rate for the Fuel Primer Pump, but will include its use in emergencies for discussion at the next CAA led YAK & Nanchang ‘Continuing Airworthiness Forum’.