2020

Noted (AI summary) BAM Nuttall was not involved in the design of the weir installation but will share the Coroner’s Report to Prevent Future Deaths with any designers of weirs in future projects where BAM Nuttall is acting as Principal Contractor. They are committed to the ongoing training of its workforce and the development of ever safer systems of work. BMM JV was not involved in construction or site operations or in the weir design, but will ensure the Report is shared with other designers in future weir projects.

Noted (AI summary) NICE notes that its guideline CG179 provides relevant guidance on pressure sore prevention in emergency departments and no further action is required, but mentions a multi-year programme to improve how NICE produces and presents guidance and advice. The Department for Health and Social Care notes the existence of NICE guidelines on pressure sore prevention and that Stockport NHS Foundation Trust has adopted a Patient Safety Checklist and improved access to dynamic mattresses.

Noted (AI summary) Highways England reviewed the A5 junction with Streetway Road and concluded that no improvements are warranted at this time. The junction will be routinely monitored for collisions and the condition of highways assets. The Department for Transport will review advice in driver learning materials and consider a hazard perception clip covering tail-swing for the driver theory test. They will also raise the marking of projections with the National Farmers' Union to remind them of the need to provide and maintain warning signs where required.

Noted (AI summary) NHS England acknowledges concerns about drug toxicity, self-certification, and not informing GPs but states the death appears to be from services outside the NHS, restating commitment to improving the safety of controlled drugs and online prescribing, highlighting existing guidelines and initiatives.

Noted (AI summary) The document provides general guidance on safer sleep practices for newborns, focusing on recommendations for reducing the risk of sudden infant death syndrome (SIDS).

Noted (AI summary) The College of Policing explains its role and details existing guidance and learning material addressing the risks associated with Taser use, particularly multiple activations, and highlights the role of SACMILL in advising on medical issues. The Home Office acknowledges the concerns about Taser use and refers to existing policy, guidance, training, and scrutiny mechanisms. It states satisfaction that current measures are adequate but acknowledges every death in police custody is a tragedy.

Noted (AI summary) Response from. UNMH University Hospitals of North Midlands NHS Trust states that Shrewsbury and Telford Hospital NHS Trust, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, has produced a Standard Operating Procedure "Referral for surgical resection of proven or suspected lung cancer" and that SaTH has implemented the SOP.

Noted (AI summary) NHS England will continue to work with HEE, the professional Royal Colleges, and other organizations to stay updated on new guidance and resources for managing severe allergies, and will explore using communication routes or commissioning levers to support their adoption. They also describe their assurance role for CCGs and commissioning of healthcare services. Advanced states they will work with NHS Digital to develop a standard for electronic updating of ambulance systems to inform them when an ambulance has been recalled. They also suggest an independent review of clinical triage systems. NICE notes that the British National Formulary (BNF) and BNF for Children (BNFc) already contain detailed advice on adrenaline auto-injectors, including MHRA/CHM advice from 2017 and 2019. It will consider how best to make clear in CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at all times. NHS Digital details changes made to NHS Pathways following the incident, including improving the Anaphylaxis algorithm, developing an audit framework, and conducting a user satisfaction survey to improve call-handling and call prioritisation. The Winchmore Hill Practice undertook an audit of patients prescribed Emerade to ensure dosage was in accordance with the BNF, reviewed AAI pen doses, and contacted patients with up-to-date advice from the MHRA. The practice has shared learning with the CCG medicine management team and amended the message on scriptswitch; any proposed changes to be made by CCG Pharmacist, will need to be approved by a Senior doctor at the practice. Bausch & Lomb distributes trainer pens to allergy clinics and is currently reviewing the design of its trainer pens to incorporate a needle cover shield extension when activated, to more closely replicate the patient experience with the actual pen. LAS clarifies the division of responsibilities for triage systems, stating that ECPAG and NHS Digital are responsible for setting categories and addressing inconsistencies between systems. LAS will discuss the PFD report at relevant user groups. The Department of Health and Social Care notes several actions, including the FSA working to get emerging trend information and alert local authorities, and working to identify means of access to relevant datasets so they can be included for analysis of food-related cases of anaphylaxis. The Healthcare Safety Investigation Branch (HSIB) will consider the matters of concern in the report and whether these meet its criteria for national investigation when the situation allows. Enfield CCG distributed a Medicines Safety Bulletin on Adrenaline Auto Injectors (AAIs) to GPs and other primary care healthcare professionals on 30th January 2020 and has contacted all GP practices. They are implementing a post-incident review and a report will be completed to ensure all actions identified are implemented to prevent a recurrence, including a review of governance processes and decision-making points.