2019

Action Planned (AI summary) RBKC and partner agencies are working together to identify ongoing needs and service developments arising from the closure of rehabilitation inpatient beds at Horton, including a potential local 'wrap around community rehab offer' with support and rehabilitation services in supported accommodation within 18 months. CNWL acknowledges the concerns raised and states that as discharge planning starts at admission, they will follow new NICE guidance on considering rehabilitation as appropriate. They offer a range of person-centred interventions and have a well-developed vocational service, offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support.

Action Planned (AI summary) London Underground will review its training for front-line station staff on spotting unusual suicidal behaviour to include customer behaviours at the gateline and ticket hall, with changes implemented by late 2019. Initial trials of new remote accessibility systems for CCTV and other systems are expected by the end of 2020.

Action Planned (AI summary) The Trust plans to incorporate awareness of Cushing's Disease into annual training for Core Medical Trainees, using the case as a study, and will discuss the case at local and Salford Royal MDT meetings to disseminate learning.

Action Planned (AI summary) The Trust is implementing a new Personality Disorder Service with a phased approach, including needs-based interventions, crisis support, peer support workers, and training for all staff, with regular review points to assess impact and adjust the service as needed. The Trust has co-produced patient-facing information, is reviewing its personality disorders strategy, has rolled out a training program, upskilled community teams, and is supporting MHPs to offer evidence-informed approaches, and is recruiting a specialist post and setting up a working group to provide for people with comorbid ASD and personality disorder.

Action Planned (AI summary) The Council has commissioned an independent road safety review of the junction and will provide a detailed report with proposals for improvements in approximately 6-8 weeks, with recommendations for short, medium, and long-term actions.

Action Planned (AI summary) One Housing will work with their property services to explore alternative fire door closures in high-risk schemes and implement ASIST suicide intervention skills training for staff.

Action Planned (AI summary) The Trust has reviewed its processes and will remind staff of nutritional status during 'huddles', paying attention to patients with changes to their oral intake. The Trust is satisfied that appropriate systems are available and in use but human factors intervened in Mr Yates' case.

Action Planned (AI summary) The Trust is delivering a learning session on record keeping and communication, emphasizing preparation ahead of appointments. The Trust is also introducing Patient Participation Leads for each locality, working alongside new Clinical Directors to lead quality and patient experience improvements.

Action Planned (AI summary) The College of Policing will examine the concerns raised in the report at the next scheduled meeting in July and bring them to the attention of the national clinical governance panel. They will also ensure liaison between First Aid and SDAR groups for consistent advice. Sussex Police will work with the College of Policing and NPCC to alter lesson plans regarding the risks of prone restraint. They anticipate introducing an electronic recording system for PST training attendance and are considering hosting a video on epilepsy on their internal website.