2022

Action Planned (AI summary) The NPCC and College of Policing outline actions taken, including updating the Death Investigation Manual and associated training to emphasize treating deaths as suspicious until proven otherwise. They have also highlighted existing guidance on handling personal effects and assessing handwritten notes, and initiated a review of the Forensic Submissions Good Practice Guide. DCMS states that the Online Safety Bill will place new requirements on companies in relation to illegal content and anonymity online and services will have to identify, mitigate and effectively manage the risk of anonymous profiles. Ofcom will set out the types of verification methods a company could use in guidance. The Metropolitan Police Service has updated its Death Investigation Policy to emphasize treating deaths as suspicious until proven otherwise and is providing refresher training to detectives. The CONNECT Investigation platform, which is replacing CRIS, will have improved functionality to track the completion of investigative actions.

Action Planned (AI summary) Following a medication error, staff received supervision and completed self-reflection. The Trust is conducting an audit, creating a Quality Improvement Plan, and plans to share learnings with the family and the coroner by the end of May 2022.

Action Planned (AI summary) The Ministry of Justice will issue an instruction to prison governors that no prisoner held in a segregation unit should be released on HDC and will prioritise necessary amendments to the Framework so that changes not being made immediately will be in place by the summer. An investigation has been instigated under Prison Disciplinary powers into the circumstances of the release including the decision made at HMP Ranby to withdraw the referral made to the independent adjudicator.

Action Planned (AI summary) NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.

Action Planned (AI summary) NHS England is working with ELFT to strengthen knowledge and understanding of transitions issues in each other’s areas and a shared transition protocol or protocols that link together. They are committed to improving the availability of inpatient mental health support and alternatives to admission for Children and Young People. The Trust has reinforced transition protocols, reviewed the serious incident report into Mr Wilden’s death and the Trust’s transition policy and protocols with relevant staff members. An administrator pulls a list of all existing service users on a monthly basis to address the transitions policy.

Action Planned (AI summary) EMAS will be sharing updated guidance, national PGD and learning from this PFD across the Ambulance Pharmacists Network. Updated guidance and training package is being developed and will be rolled out during 2022/23 which will include the option for clinicians to administer buccal midazolam to adults (18 years and over) who present with convulsive status epilepticus when it is not available within the home as a prescribed medication.

Action Planned (AI summary) EMIS is reviewing and will update the EMIS Web Hazard Log and Safety Case to reflect identified concerns; highlighting established system and training mitigations. EMIS is reviewing training material relating to the filing of results, to include reference to those results that may require a more detailed review, such as radiology results. The Neurology team has stopped using the “file no Comment” button in favour of the “File and Comment” button. The Trust has notified colleagues in Primary Care and anticipate implementing a RAD system in April 2022. The neurology team has stopped using the 'file no comment' function and increased vigilance when reviewing results. A new standard operating procedure was developed and reports containing the text "significant radiological finding" have been flagged in the ICE system. A RAD alert system is being piloted to email consultants/GPs about significant radiology findings.