2020

Noted (AI summary) Manchester University NHS Foundation Trust provides context on policies and procedures regarding neurosurgical referrals, head injury pathways, and anticoagulation management. They express sorrow for the patient's death and state that clinicians are required to follow these standards.

Noted (AI summary) Stockport Clinical Commissioning Group states that the correct processes and pathways were followed from the point of consultation with the GP through to the ordering of the echocardiogram and referral to specialist cardiology services. Initial investigations were completed prior to referral in a timely manner.

Noted (AI summary) The Trust has policies to protect meal times and regularly screens patients for malnutrition. They have completed a mini-accreditation for nutrition and hydration compliance on all inpatient wards and have shared a 'seven minutes briefing' session focused on nutrition. They have also made available an intranet microsite for Nutrition and Hydration. Greater Manchester has developed principles to prevent patients being redirected to A&E due to lack of ward capacity, requiring specialities to accept direct referrals unless patients are clinically unstable. They have also implemented guidance to reduce delays in discharging patients to community beds, including a single referral form, triage within 30 minutes, and 2 weeks of medication on discharge. Stockport Trust has also implemented an Integrated Transfer Team and a Discharge to Assess hub. The Department of Health and Social Care acknowledges the concerns raised and notes regulatory action taken by the CQC. It highlights existing NHS guidance and funding aimed at improving discharge processes and community care.

Noted (AI summary) NHS England notes the Trust's response and states it is promoting the free online Just and Learning Culture training to NHS employers. The Trust acknowledges failings in care and communication and has implemented several changes, including red flag identification, a revised Serious Incident Panel process for 12 months, and a local Serious Incident Panel to review serious incidents requiring further response, and implementation of Patient Safety Incident Response Framework (PSIRF). A mortality review process is also embedded at Trafford General Hospital. The CQC acknowledges the concerns and explains the statutory notification process. While stating that current reporting processes are adequate, it will review existing notifications guidance to determine if it could be clearer about reporting requirements relating to the circumstances of a person’s death. The Trust has updated its falls investigation template to include more detailed guidance around immediate action, including checking and documenting the environment of a fall. The CQC will review its existing notifications guidance in light of the findings from the death.

Noted (AI summary) The DBS acknowledges the coroner's concern about the lack of statutory international criminal conviction checks and explains its role in providing DBS checks for employment in England, Wales, the Channel Islands, and the Isle of Man. It outlines the types of DBS checks available and directs the coroner to existing guidance for employers regarding applicants who have lived or worked outside the UK.