2019

Action Taken (AI summary) The University Health Board has implemented an Organisational Development Action Plan, including study days and mandatory training on communication and escalation, and has fully implemented PROMPT training. They have also implemented a new escalation policy, senior midwife on-call rota, and a birthrate plus acuity system for the labour ward.

Action Taken (AI summary) The trust issued a "Red Top Alert" to medical personnel regarding NICE guidelines for prescribing anti-depressants (CG90), including communication with primary care and documentation. It will also be discussed at various meetings across the trust to share learning. The Department acknowledges the concerns and highlights existing guidelines and initiatives, including updated NICE guidelines on antidepressant prescription and various government-funded projects to improve student mental health support and reduce suicide risks. The University practice now books appointments to review patients starting SSRIs within one week, and clinicians ideally book the next appointment before the patient leaves, with a message to alert staff if the patient cancels. They've also requested funding for a Mental Health Nurse.

Action Taken (AI summary) Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points and random spot checks are undertaken to reduce the risk of stockpiling. The Safer Custody Governor is recommending awareness of in-possession medication risks is included in case manager training. HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, with risk assessments informed by healthcare. A safety briefing on in-possession medication has been distributed and ACCT case manager training will cover stockpiling medication. The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger opening an ACCT. The case was reviewed with involved staff, and learning shared.

Action Taken (AI summary) The Trust has implemented an Accessible Information Standard Policy, an Interpretation and Translation Procedure, and guidelines for the care of people with learning disabilities. It flags Blackpool residents with learning disabilities on electronic patient records and is working to extend this to Lancashire residents. A Red Alert has been issued to staff reminding them of vigilance for peritonitis in post-operative PEG tube patients.

Action Taken (AI summary) An independent review of the UK search and rescue (SAR) operational capability and functionality will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. A review of SAR information technology systems has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May.

Action Taken (AI summary) Following an RCA, the Trust has audited ED staff compliance in completing documentation, with poor initial results leading to monthly repeats and discussion by senior management. The Trust reiterated that patient safety overrides national targets.