2020

Action Planned (AI summary) The Royal London Hospital departure lounge changed its practice to ensure that staff document address changes in the patients electronic record in line with trust practice and clarified in their SOP that when patients are discharged staff check the address they are going to with them directly. LBTH will reiterate the importance of adhering to the Failed Visits policy to commissioned providers at the next forum, and the lead commissioner will remind Sue Starkey House of the importance of informing the emergency duty team if a patient does not arrive as expected from hospital discharge.

Action Planned (AI summary) The RCR has invited its Radiology Informatics Committee to revisit its guidelines to double check that they are clear and unambiguous in their specifications regarding IT equipment standards. The Trust is developing an Abdominal Pain Pathway aiming for CT scans within 2 hours for Emergency Department patients with abdominal pain, expecting it to be in place by the end of October 2020. They have also created an Escalation Handovers Pack for junior doctors, with the Royal College of Emergency Medicine planning to host it on their website.

Action Planned (AI summary) The Trust will reinforce with staff the requirement to record sight of a registered LPA, review the 'Communication with Relatives Procedure', and explore options for implementing electronic flagging of patients lacking capacity.

Action Planned (AI summary) The MHRA reviewed evidence on doxycycline and psychotic reactions. Based on expert advice, they will request that the lead marketing authorisation holder submit a proposal by 30 November 2020 to gather further data on the risk of psychotic reactions following doxycycline.

Action Planned (AI summary) The Trust is reviewing its recruitment process for doctors to ensure appropriate training and induction, with changes to be implemented by the end of September 2020. The trust also describes existing processes for assessing locum doctors, offering substantive contracts after frequent employment, and encouraging staff to raise concerns. Dr. referred himself to the General Medical Council following the inquest. He has also been proactive in his efforts to improve his knowledge and partake in training for obstetric emergencies including completing the K2 Training Program.

Action Planned (AI summary) Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.

Action Planned (AI summary) Durham County Council plans to install measures by March 31, 2021, to deter pedestrian access to the A690 dual carriageway, including proactive signage, guardrail, wayfinding signs, foliage clearance, and removal of access to a public footpath.

Action Planned (AI summary) The IMB will deliver training to all immigration detention IMB members by the end of 2020, and require it for all future members with refresher training every three years. The training will focus on monitoring those in separation, raising concerns, and responding to allegations of abuse. The Trust is developing robust educational pathways within Offender Care and will develop a “train the trainer” programme to enable local sites to provide mental health awareness training routinely. The Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms and will be circulating it as a standalone document to all CNWL staff and to all partner agencies by the end of November 2020.

Action Planned (AI summary) The hospital will provide training to staff on pre-alert calls for silver trauma cases by September 30, 2020, review the protocol for referrals to the Spinal Team via OARS (expected to take at least 3 months), and increase awareness of 'Dalteparin' guidelines. They also plan to share an internal investigation once completed.