2019

Action Planned (AI summary) The Department of Health and Social Care is developing a learning disability and autism training package to be tested in 2020/21, with wider rollout planned after evaluation. They will also amend the Health and Social Care Act 2008 to mandate relevant training for NHS and social care staff.

Action Planned (AI summary) NHS Birmingham and Solihull ICB is allocating funding towards community based crisis support services run by MIND and crisis houses to complement inpatient mental health facilities. BSMHFT is also actively recruiting staff into the Home Treatment Team and other services.

Action Planned (AI summary) Network Rail is issuing a National Safety Bulletin to Off Track teams, completing a special topic audit on compliance with the new boundary inspection standard, and reviewing national data. These actions are tracked via the Network Rail CMO-Compliance Tracked Action system.

Action Planned (AI summary) • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin will reference the key learning from this tragic event, specifically stating that where a team is unable to view a boundary fence from trackside due to vegetation, they must view the fence from the other (public) side. • The National Safety Bulletin will also state that if the fence cannot be viewed from either side, the team must record this and escalate it to their supervisor.

Action Planned (AI summary) The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients, and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective.

Action Planned (AI summary) NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system.

Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has developed a process for joint working between teams for complex cases, implemented a risk assessment process for transfers, and is planning a multi-agency meeting to plan a learning event, following recommendations from a review. The Queen Elizabeth Hospital reports that a multi-disciplinary meeting has been held and a learning event is planned for February 2020, with the West Norfolk CCG taking the lead on organisation. The CCG is organizing a multi-disciplinary learning event for NSFT, QEH, NCC, and EEAST staff to address concerns raised in the PFD, with an external facilitator identified and a date in mid-February 2020 planned. The event will include a pen portrait of the deceased, wishes from their parents, and messages from involved staff. Norfolk County Council commissioned a Serious Case Review with findings and recommendations and a learning event has taken place on 7th November 2019. A further event will take place in early February 2020.

Action Planned (AI summary) The Trust has implemented measures to improve ambulance turnaround times, including daily meetings to review patient flow, screens displaying ambulance information, purchasing additional trolleys, and having Ambulance Liaison Officers on site during high demand. The Trust also joined a Phase 2 NWAS ambulance handover collaborative project. Blackpool CCG emphasized a Roster Review in commissioner requirements and are involved in initiatives to improve hospital handover times by using improvement methodology with several hospitals. They are also part of a North West Handover Improvement Board. NWAS is trialing a pilot program in the Cheshire and Mersey EOC to manage meal breaks differently, involving a mandatory staggered stand down of resources. They will also be adding 250 paramedics to the service by March 2020. The Department of Health and Social Care outlined actions to improve ambulance services, including implementing an improved ambulance performance framework, issuing revised hospital handover guidelines, and improving monitoring and reporting of patient handover delays. They also made the AACE aware of the coroner's concerns.

Action Planned (AI summary) HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.