2020

Noted (AI summary) The Office of Rail and Road (ORR) acknowledges the report but states they do not have the power to take the actions proposed; they recommend the report be directed to Docklands Light Railway Limited (DLR), Keolis Amey Docklands (KAD), and TfL. The ORR says DLR is keeping the topic of obstacle detection under review. TfL and Keolis Amey Docklands will enhance the visibility of platform alarms and continue to work towards a possible trial of CCTV obstacle detection technology; they will also discuss platform CCTV with other light rail operators.

Noted (AI summary) Sydenham Green Group Practice has implemented a policy requiring parental agreement and phone calls on the first day of 'rescue pack' antibiotic use, held a practice meeting to discuss the case, and adapted training material to include themes arising from the case; the GPs have reviewed and updated the practice safeguarding policy. The Royal College of Paediatrics and Child Health offers advice on communication and care planning, including the importance of named neurodisability pediatricians, health care plans, and communication between parents and health professionals; the college also points to resources on sepsis recognition and management. The London Ambulance Service plans to update its OP/014 Managing the Conveyance of Patients Policy and Procedure by the end of October 2020 and is participating in a coordinated meeting with other agencies to discuss inter-agency working; the LAS has safely, efficiently and effectively access PSPs through CMG.

Noted (AI summary) The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The RNLI is revising plans to provide lifeguard cover on additional beaches, working with landowners and councils to confirm beaches and timings for public announcement. The MCA reiterates its role in coordinating search and rescue, clarifies that it has no statutory responsibility for beach safety, and states that it will continue to work with partners on safety campaigns.

Noted (AI summary) The RNLI is revising plans to increase lifeguard cover on beaches, working with landowners and councils to confirm beaches and timings, with public announcements to follow. The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The MCA states they have no statutory responsibilities for beach safety, but continue to work with partners on safety campaigns, including a joint campaign with the RNLI; they are ready to support the inquests.

Noted (AI summary) The Trust has undertaken multidisciplinary education programmes on accurate fluid balance monitoring and audits completion of fluid balance charts; clinical staff complete clinical induction days, and critical care outreach teams provide support and teaching to ward staff. NHS England states that while they do not develop clinical pathways, national bodies have, and hopes that this case has been used at the Trust for reflection, learning, and action.

Noted (AI summary) An Electronic Patient Record (EPR) has been introduced. Mental Capacity Act (MCA) training is being provided and MCA forms are available on the EPR. A competency framework has been developed for the Home First team, and transfers will be reviewed daily; wards have been advised that the decision to reduce the level of enhanced care should not be undertaken by ward staff without a full multi-disciplinary meeting. Bolton Council and BNFT have advised all wards that the decision to reduce enhanced care levels should not be undertaken by ward staff without a full multi-disciplinary meeting, instructed Ward Managers that any patient with complex needs should be escalated to the integrated discharge team, and are developing a skills and competency framework. Learning from the inquest was shared with senior management and leadership teams, with an action plan to ensure staff are up to date with Best Interest & Capacity Training and CPA training. Staff have been informed of care coordinator expectations when patients are in alternative care settings. The Department of Health and Social Care acknowledges the concerns and points to existing guidance and rights regarding mental capacity assessments and care planning.

Noted (AI summary) The Department for Transport expresses sympathy and acknowledges the coroner's report. The response states the department is opposed to extending exemptions to road traffic laws and describes that existing laws and procedures did not appear to be followed in the incident.

Noted (AI summary) The CQC acknowledges the report and details its role as a regulator. It notes actions taken by the care home and Tameside Local Authority, including new handover sheets and risk assessments, and states the CQC is satisfied appropriate steps have been taken. The response acknowledges the concerns and refers to the CQC's review and satisfaction that sufficient action has been taken. It then discusses national guidance on PPE disposal, waste management, care plan reviews, and dementia training.