2021

Action Planned (AI summary) North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, audit implementation of the checklist, update the HTT service operational procedure, and update the Trust’s Clinical Handover of Care and Discharge Policy. The Department of Health and Social Care acknowledges concerns and highlights the NHS Long Term Plan and the COVID-19 mental health and wellbeing recovery action plan, which includes funding to expand community mental health services and support suicide prevention work.

Action Planned (AI summary) NHS England and NHS Improvement are improving adult eating disorder services with a national programme backed by investment. They are also improving data on the prevalence of eating disorders in adults, joining the APMS steering group to influence questionnaires. The GMC has used its regulatory powers to address inconsistency in training to address patient safety concerns, and is working with medical schools to ensure ED training is delivered more consistently. A new e-learning programme for medical students and foundation doctors has been launched, and existing curricula have been updated. The Department of Health and Social Care acknowledges concerns about eating disorder treatment and highlights the Mental Health Recovery Action Plan, which includes significant funding to expand children's and adult mental health services, including eating disorder services. HEE has a range of high quality training available via its e-Learning arm, e-Learning for Healthcare, around eating disorders, particularly on its MindEd programme, which is targeted at professionals and their families. This training includes a new programme for medical students and foundation doctors, developed in partnership with RCPsych and the eating disorder charity, Beat.

Action Planned (AI summary) Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, including improving communication, training, and referral processes, while also addressing factual inaccuracies in the case review.

Action Planned (AI summary) Since Mr. Agnew's death, City of London Police officers receive further training on assessing intoxicated persons. First aid training of City of London Police officers now includes training to recognise that snoring in a person with a reduced level of consciousness is a sign of airway obstruction and to perform the "jaw thrust" manoeuvre. The College of Policing will use the coroner's concerns to inform a review of the learning outcomes for the FALP (roads policing) programme, which will take place this year. The College has developed a vulnerability learning programme which supports the PCDA programme. Since 2016, the Mayor of London has established a night transport outreach team that assists rough sleepers on the transport network, helping over 1,020 clients. The team enables drivers and others to refer those of concern to this service.

Action Planned (AI summary) Whittington Health is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, with regular audits to monitor compliance; the guidance will be ratified in August 2021. The service has reviewed its processes for private carer arrangements and will document agreed care plans with families in the electronic patient record.

Action Planned (AI summary) The ambulance service does not believe a Safety Alert would be appropriate and do not believe that it is feasible to upgrade all overdoses, but plans to meet with the NHS England national ambulance team and NHS Pathways to share learning and progress concerns. Revised guidance on overdoses is at the pre-publication stage and will endorse clinical review of overdoses.

Action Planned (AI summary) The LAS has implemented leadership training and Acute Behavioural Disturbance (ABD) refresher training. They collaborated on national guidance for ABD for ambulance staff and are sharing updated clinical guidelines via tablet devices. Learning from the death has been presented to the JRCALC guidelines group. The MPS will include information in officer safety and emergency life support training on Acute Behavioural Disturbance (ABD) and de-escalation techniques, the impact of stress on behaviour, and reflection on actions. Supervisors will be trained to identify themselves and liaise with the Safety Officer upon arrival at a scene.

Action Planned (AI summary) The care home is under notification to close and transitioning to a new provider. The new management team is developing safe operation of the home including enhanced leadership, new compliance and care planning systems, increased training, and health and safety audits.

Action Planned (AI summary) CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online prescribers, working with other regulators and government organizations to address current and emerging threats. The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from a review focusing on medicines associated with dependence, including structured medication reviews for patients.

Action Planned (AI summary) The hospital plans to implement changes including a daily review of post-operative patients by consultants, ceasing elective operations on Fridays, and providing mandatory training for junior doctors on escalation pathways and resuscitation.

Action Planned (AI summary) Capita is pausing the issue of appointment letters during Change of Assessment or Further Review periods. They are also working with DWP to review the tone and language in written communications. Full implementation of the changes will be in place by 30 September 2021. The DWP has already introduced a highly visible "watermark" in the PIP computer system showing if a customer has additional support needs. Script changes to better support vulnerable claimants will go live by the end of May 2021, and strengthened wording regarding DLA will be introduced by early May 2021.

Action Planned (AI summary) Epilepsy Action will amend its online information by the end of June 2021 to extend advice about bathroom doors to any door to any confined space. It will also publish an article in its magazine and notify healthcare professional contacts about the issue. The RCPCH will share learning from the death with paediatric specialty groups and OPEN UK to raise awareness of home environment risks for children with epilepsy. They also suggest SUDEP Action could adjust advice on door opening in their resources.

Action Planned (AI summary) The national Safe Working Practice document for Approved Premises is being re-issued on April 30th 2021 and all staff must read the updated SWP and sign a register to confirm this and that they understand the processes. The National Approved Premises Team will also review the EQuiP usage data for approved premises staff to identify any areas where EQuiP usage falls below average and will undertake an awareness raising exercise to reinforce the importance of EQuiP.