2020

Action Planned (AI summary) NHS Digital will bring the circumstances surrounding the death to the attention of a programme that is rationalising and streamlining the systems and data flows in the management of primary care registration. This is so that improvements may be considered through appropriate consultation with system users and stakeholders.

Action Planned (AI summary) Southeastern will replace warning signs at Canterbury East station, engage with a local nightclub to educate patrons about railway safety, review risk assessments for the station, and share findings with the wider railway community. Most actions are planned for completion by March/June 2021. Southeastern replaced warning signs at Canterbury East station with a new design. They also provided Chemistry Night Club with posters and drinks mats highlighting railway safety messages, reviewed risk assessments, and shared learning with the wider industry.

Action Planned (AI summary) Jet2.com has updated its Ground Handling Manual to include procedures for supporting vulnerable passengers, including contacting family/friends, embassies, or other services. Training will be updated using the case as a study, and the CAA has approved the amended procedures. The Civil Aviation Authority (CAA) will explore how to define vulnerable consumers, propose improvements to their treatment in the UK aviation industry, and increase engagement with industry. The CAA Executive will receive a report in Q1 2021 and review progress regularly.

Action Planned (AI summary) NICE guidelines on postnatal care and neonatal infection were being updated to address concerns about monitoring mothers/babies after discharge and assessing babies when mothers are admitted with infection. The Royal College of Paediatrics and Child Health will continue to advocate for adequate resources in child health. NICE updated its guidance for postnatal care (NG194) to include a recommendation addressing the assessment of the baby where the mother has symptoms or signs of sepsis. The scope of its updated guidance for Neonatal infection (NG195) also covers late neonatal infection.

Action Planned (AI summary) The Trust has reiterated the need to document verbal advice and information, continues to audit medical records, and has embedded documentation of specialist advice in the curriculum for Junior Doctors. The Trust is introducing Electronic Patient Records in December 2021. The GMC will consider the information provided and determine whether any further action is required either through their Outreach or fitness to practise process. Ashford and St. Peters Hospitals emphasizes documentation of specialist advice in training for junior doctors and at Trust events. They will further strengthen documentation by introducing Electronic Patient Records in December 2021. The GMC has opened a provisional enquiry into the actions of one doctor and will obtain clinical records and an independent clinical opinion. No further action will be taken regarding the other doctor. The RCS will consider the coroner's concerns in its 2021 programme of standards and good practice guidance review and development, and shared the correspondence with the British Orthopaedic Association. The BOA will set up a short life working group with haematology colleagues to explore producing guidance on managing complex cases regarding thromboembolism prevention. The RCP has highlighted the need for standards to confirm the accuracy of verbally given advice as a member of PRSB and proposed standards for remote advice documentation based on COVID-19 pandemic learnings. The RCP continues to advocate for integrated electronic record systems.

Action Planned (AI summary) The department will raise the concern that the statutory minimum provision of smoke alarms is less than the maximum offered in British Standard 5839 with the relevant committee at the British Standards Institute for consideration, as part of a full technical review of the standards that support building regulations.

Action Planned (AI summary) The Trust will introduce a referral requirement for on-call psychiatrists in specific risk scenarios, amend assessment templates to include consideration of family concerns, implement monthly supervisions for bank staff, introduce regular learning sessions from serious incidents, and review advanced clinical risk training with relevant case scenarios.

Action Planned (AI summary) The Trust and BHCC are developing a joint policy and guidance to improve communication and define responsibility between the organisations to improve the safety of voluntary patients waiting for acute mental health beds. Actions include reviewing existing policies and protocols, implementing new documentation procedures, and providing staff training, to be completed by April 2021.

Action Planned (AI summary) The CCG has agreed to extend the current peer support worker provision until March 2022 and is transforming community mental health services as part of the Long-Term Plan, which includes peer support workers. The transformation model is due to be submitted to NHS England in January 2021.

Action Planned (AI summary) Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.