2021

Action Planned (AI summary) Two task and finish groups will review Section 42 and Multi Agency Adults at Risk System processes, with learning to be shared with the Greater Manchester Quality Board and commissioners of services. GMP has implemented the vulnerability assessment framework to identify and assess risk factors, and officers now record care plans after safe and well interviews with vulnerable adults.

Action Planned (AI summary) Cornwall Council will erect additional warning signs at the Trebost junction at Tubbon Hill, following the coroner's recommendation.

Action Planned (AI summary) CQC will undertake a focused inspection of Lisburne Court, including staffing levels, training, and infection control, and meet with the Chief Executive and new Nominated Individual of Borough Care Limited to discuss the issues raised and seek assurances. Stockport CCG has improved communication between hospital, GP and community services via a common system. GMHSCP is working across the system to look at safe discharges for people with complex needs and has a Learning Disabilities Complex Needs programme underway. The Department of Health and Social Care is preparing a new Dementia Strategy. NHS England and NHS Improvement are working with regional and local partners and the CQC. The CQC are to meet with the Chief Executive of Borough Care Ltd in the interim, to discuss these matters and to seek assurances around the lessons learned from this incident.

Action Planned (AI summary) Tameside and Glossop Integrated Care NHS FT implemented a mobile MRI scanner offering additional outpatient scanning capacity. GMCA GMHSCP are promoting Diagnostic Radiography during career events in 21/22. A NW implementation plan for the next 5 years will be developed. NHS England and NHS Improvement are targeting funding to support diagnostics via the development of community diagnostic hubs which will augment access for inpatient activity in acute hospital services. Expansion of the imaging workforce is being developed in tandem with Health Education England (HEE).

Action Planned (AI summary) Medway NHS Foundation Trust is developing a new Standard Operating Procedure and is actively exploring options to source additional falls alarm equipment. A new escalation process will be implemented for non-availability of falls equipment; this will be included in the SOP.

Action Planned (AI summary) The Trust will update its CPA policy and Acute Care Services Operational Protocol to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge. The CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust.

Action Planned (AI summary) The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.

Action Planned (AI summary) NHS England and Improvement are working with the Healthcare Safety Investigation Branch (HSIB) testing and introducing national patient safety incident investigation training and developing a patient safety incident investigation training procurement framework. GBUK Enteral Ltd has revised device labelling and Instructions For Use (IFU) to remove references to drainage, add warnings about flow restrictions with ENFit connectors, and clarify the intended use as a feeding tube. They have also provided refresher training to sales staff and requested NHS supply chain to update the device description on their website. The Trust has designed a new proforma for evaluating equipment and has updated the Trust e-learning training package for the insertion and on-going management of Nasogastric/Orogastric tubes including troubleshooting guidance and a competency and self-assessment document. The manufacturer has updated the product labelling for the Carefeed devices to remove the secondary intended use of drainage; MHRA will write to UK manufacturers of nasogastric tubes to advise them of the risk associated with the use of the ISO standard ENFit connector in aspiration/decompression situations and ask them to update their risk assessment and is collaborating with NHS England and Improvement on raising awareness on the Medical Devices Safety Officers' (MDSO) network.

Action Planned (AI summary) The manufacturer has updated the product labelling for the Carefeed devices to remove the secondary intended use of drainage; MHRA will write to UK manufacturers of nasogastric tubes to advise them of the risk associated with the use of the ISO standard ENFit connector in aspiration/decompression situations and ask them to update their risk assessment and is collaborating with NHS England and Improvement on raising awareness on the Medical Devices Safety Officers' (MDSO) network. GBUK has revised device labelling and instructions for use, removing all references to drainage and adding warnings about flow restrictions with ENFit connectors and has provided refresher training to its sales force regarding nasogastric feeding tubes and ENFit connectors. The Trust has designed a new proforma for evaluating equipment and has updated the Trust e-learning training package for the insertion and on-going management of Nasogastric/Orogastric tubes including troubleshooting guidance and a competency and self-assessment document. NHS England and Improvement are working with the Healthcare Safety Investigation Branch (HSIB) testing and introducing national patient safety incident investigation training and developing a patient safety incident investigation training procurement framework.

Action Planned (AI summary) Kirklees Council will extend the northern footway by 18m to improve pedestrian crossing opportunities on Barnsley Road. These works are part of a footway maintenance scheme started on May 7th 2021.