2021

Noted (AI summary) The Health Board reviewed nurse staffing levels which they state were adequate at the time of the incident. They have also commissioned an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital, and a similar review of medical staffing is also being undertaken.

Noted (AI summary) The Department acknowledges the concerns regarding the 2010 Risk Assessment Tool for Venous Thromboembolism (VTE) and refers to NICE guidelines. They note the need for further research to balance VTE risk versus bleeding risk in acute psychiatric settings and that the National Patient Safety Committee will work to identify the best route to take this forward.

Noted (AI summary) The Trust states that changes were implemented following a Serious Incident investigation. They describe using AFLOAT to assist with setting observation levels, but the final decision is based on the nurse's professional judgement.

Noted (AI summary) The MHRA will engage with the medical device safety officers (MDSO) network to raise awareness of possible incidents involving filters and encourage reporting and will write to known manufacturers of filters to ask them to conduct a review of the labelling of filter devices against the regulatory requirements, taking into consideration the findings of the inquest, and making improvements where identified. The response provides background information on HME/filters, potential issues, and proposes solutions such as standardized color coding and clearer labeling, but does not commit to any specific action. The organisations will highlight key lessons about breathing circuit filters to their membership through the Safe Anaesthesia Liaison Group’s Patient Safety Update and FICM Safety Bulletin, and have suggested that NHS Improvement undertake a formal analysis of the NRLS database to assess the frequency of incidents arising from incorrect filter use. The MHRA will work with manufacturers, other regulators, NHS England and Improvement and other stakeholders to explore the effects of actions such as reducing filter types and improving color coding, and will engage with the medical device safety officers (MDSO) network to raise awareness and improve incident reporting.

Noted (AI summary) Nottinghamshire County Council asserts its duty to protect public highway rights regarding level crossings, clarifies the roles of Network Rail and the public in crossing closures, and states it has been supportive of safety improvements. Derbyshire County Council provides an explanation of their previous involvement in a 2003 proposal to divert Public Footpath No.7, and clarifies that they will work with other agencies to improve safety across the County. Network Rail acknowledged past unsuccessful attempts to change level crossings in the area and expressed willingness to work with local authorities to find potential solutions. Broxtowe Borough Council has scheduled a meeting with Network Rail to seek potential solutions to concerns raised, and will provide further information after the meeting. Erewash Borough Council stated that they previously supported Network Rail's Level Crossing Closures Programme, and would still not oppose the closure of the Barton Road crossing if Network Rail recommends it, though they prefer an accessible footbridge.

Noted (AI summary) NHS England notes that the Trust has responded adequately at a local level and that the matters of concern have been dealt with, and has shared the Regulation 28 Report and both responses with the Regional NHSE/I teams. Immediately following the inquest, the hospital sourced 10 zimmer frames and made them available in the ED; a process for procurement, storage, labeling and auditing of walking frames was fully implemented in early July.