2019

Action Planned (AI summary) The Trust acknowledges concerns about the Crisis team's service and states that it has received additional investment of £962k to enhance the service. An audit reviewing patients open to Crisis Services between September 2018 and September 2019 will be completed by end of November 2019 to establish the band of staff and the number of visits they have completed. Additionally, the Trust will review local guidance for staff on pre-visit preparation.

Action Planned (AI summary) The Health Board reported the death to the Medicines and Healthcare products Regulatory Agency (MHRA). A project proposal is in development by the Mental Health Clinical Board, Pharmacy and Information Technology to develop an interface between PARIS and PMS to improve the transfer of information.

Action Planned (AI summary) NHS England is reviewing the evidence for DPD testing, with a decision expected by April 2020 on whether to routinely commission it. Steps have been taken to ensure a supply of uridine triacetate within England, and an urgent policy statement is expected to be published in March 2020.

Action Planned (AI summary) The City and Hackney HTT will provide additional training during its away days scheduled for 4 and 5 December 2019, including reviewing the core competencies and standard of risk assessment required by clinicians and reinforcing the standard of medical record taking. Additionally, the City and Hackney HTT will be rolling out a new protocol on checking outstanding work following sickness.

Action Planned (AI summary) The DHSC refers to the National Prison Partnership Board, which published a Principle of Equivalence in October 2019 to ensure equitable healthcare outcomes for prisoners. NHS England and NHS Improvement have taken steps to review and strengthen its quality assurance and contract performance systems. Following the death, NHS England has moved to a single provider model for healthcare in prisons to negate communication issues and ensure a single database system. Care UK was awarded the contract in October 2019, with services being mobilized for an April 2020 delivery date and oversight via contract review meetings. HMP Lewes is committed to providing resources for external escorts to medical appointments and currently makes sufficient staff available for three external hospital escorts each weekday. There is a daily meeting between prison and healthcare staff at which important information is shared.

Action Planned (AI summary) NHS England reports that it has reviewed its commissioning contract performance and quality assurance systems following the death. Improvements include a revised governance structure with a Quality Board and Serious Incident Panel, and the appointment of a dedicated Quality Assurance Team. The Department of Health and Social Care states that providers of healthcare services are responsible for the quality and safety of the care they provide and expects the healthcare providers at HMP Lewes to consider improvements. The National Prison Partnership Board published a Principle of Equivalence in October 2019. HMPPS published the Prisons Drug Strategy in April 2019 and each prison has responsibility for reviewing their own local substance misuse strategy. A notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code and the prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.

Action Planned (AI summary) West Midlands Police has reviewed its call handling procedures, including providing additional training, instituting a "Log Closure Doctrine", reducing the number of logs held by each dispatcher, changing the dispatch model and shift patterns. They are also developing a new Command and Control platform to support call handlers. The Home Office will ask officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. The Home Office states that public safety remains the government's number one priority and cites increased police funding and plans to increase officer numbers. West Midlands Police accepted that the 101 call was incorrectly graded and has discussed this with the staff member in question, and has promised additional training for all control room staff. They have also instituted a "Log Closure Doctrine", reduced the number of logs held by each dispatcher, changed the dispatch model and shift patterns, and are developing a new Command and Control platform.

Action Planned (AI summary) Newcastle City Council commissioned two independent Road Safety Audits and will install text on the kerb edge at pedestrian crossing points stating 'Look both ways'. Other minor scheme improvements include amending tactile paving, revising the phasing of lights, and replacing damage on a splinter island.

Action Planned (AI summary) The hospital will conduct an education and awareness event at the next Orthopaedic Governance Meeting, introduce an additional step to the electronic discharge procedure, publish a VTE risk assessment template/flyer, and discuss changes to the pre-operative checklist with the Head of Anaesthetics.

Action Planned (AI summary) The Department of Health and Social Care will review the care system, give local authorities a 4.4% real-terms increase in their Core Spending Power, and will be made available to all areas and CCGs, and through them to every school and college (including alternative provision settings) and children and young people's mental health services in England.