2021

Noted (AI summary) The Department of Health and Social Care will include a link to falls and fractures guidance within its Coronavirus (COVID-19): admissions and care of people in care homes guidance. The Department will also seek clarification from Public Health England and NHS England and NHS Improvement regarding adjustments to falls and fractures guidance for self-isolating care home residents. The CQC acknowledges the PFD report and explains its role as a regulator, including inspection methodology and enforcement actions. It notes ongoing monitoring and liaison with the local authority, but does not outline specific actions taken or planned in direct response to the report.

Noted (AI summary) The CQC acknowledges the PFD report and details actions taken following a notification of death and whistleblowing concerns, including an inspection and review of falls management. They will continue to monitor information received about the service until the next inspection. Castlehill Specialist Care Centre has fitted individual door sensors in every bedroom, installed new monitoring screens linked to the external doorbell, and will make 111/999 calls following any fall. They will also raise safeguarding alerts and request 1:1 funding following any fall.

Noted (AI summary) Norfolk County Council Adult Social Services expresses concerns about the inquest process, stating they were not asked to provide a report or contribute to the inquest. The response focuses on providing context and disputing some of the findings, particularly regarding the availability of suitable placements. Norfolk and Norwich University Hospitals NHS Foundation Trust is seeking funding for a ward-based Dementia Support Worker, and has been providing regular support by the Dementia Support Team. They have reviewed the Falls Risk and Safety Sides assessments, with a final draft completed and at the final adjustment/review stage, with plans for staff education to support the changes.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the planning and commissioning of local health services is the responsibility of CCGs. They note that Stockport CCG has responded and that Mastercall has undertaken to conduct a full audit of the ATT service. Stockport CCG has addressed concerns about the ATT service by agreeing that any visit required following initial telephone assessment will be performed by Mastercall, with exceptions only when a GP expresses a preference. The CCG is working with Mastercall and the wider primary care system to remove a 'grey area' in the service criteria.

Noted (AI summary) The RCPCH acknowledges the concern about Vitamin D supplementation advice in the Red Book, but states that the current edition already contains relevant guidance. They suggest the issue is one of professional practice rather than a deficiency in College standards. NICE states that their guideline PH56 already recommends including questions about vitamin D supplements in the Red Book, and that the RCPCH is best placed to amend the book's content. NICE will liaise with NHSX and NHS Digital to improve alignment between digital content and NICE guidance. They will consider the coroner's report when the guideline is next reviewed. The Department acknowledges concerns about vitamin D supplementation and highlights existing guidance and the Healthy Start scheme. They refer to an ongoing review into improving health outcomes in babies and young children but do not commit to any specific changes to vitamin D policy.

Noted (AI summary) West Midlands Ambulance Service took immediate action by informing all frontline staff of requirements for medical gas cylinder assembly/disassembly and sharing lessons learned with partner organizations. The CQC acknowledges the concerns but states it is outside of their remit to issue or change formal guidance or policies around oxygen usage or safety, as they are not clinical experts. They will continue to communicate with WMAS and monitor actions taken to improve safety. HSE will support MHRA as the lead authority and will use its communication channels to promote any information/guidance produced by the MHRA. They will also consider if HSE guidance document INDG459 should be updated to reflect any new information/guidance produced. MHRA has commenced a dialogue with the Association of Anaesthetists and the Safe Anaesthesia Liaison Group of the Royal College of Anaesthetists to raise awareness of ignition within valve components of oxygen cylinders. MHRA was represented on a multiagency group which hopes to publish guidance once ratified by the Councils of both the RCoA and the AA.