2022

Action Taken (AI summary) Tameside and Glossop ICFT has implemented a fractured neck of femur improvement programme, monitors compliance daily via the Divisional senior leadership team, and submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture.

Action Taken (AI summary) Tanglewood Cloverleaf Care Home has enhanced monitoring and auditing processes, introduced a new e-learning platform, focused on nutrition and hydration training, employed a care plan manager, and amended the Nutrition & Hydration policy to include current practice of monitoring and recording all intake.

Action Taken (AI summary) The Trust has developed a Section 117 Aftercare Policy, updated training for staff on Section 117 responsibilities, and updated their clinical record system to automatically flag patients eligible for aftercare. They will also hold a learning event on safe discharge and 117 responsibilities.

Action Taken (AI summary) East London NHS Foundation Trust has facilitated physical health simulations training across inpatient units and is undertaking them at least monthly in all units, with weekly ward managers meetings to plan simulation exercises; the electronic recording system for NEWS2 now has automatic alerts for all physical health observations recorded which are outside expected limits. East London NHS Foundation Trust has implemented an action plan that includes medical simulation training, Life Support training, and training on the correct escalation of patients with chest pain, and the electronic recording system for NEWS2 now has automatic alerts for all physical health observations recorded which are outside expected limits; a monthly audit of the ward in relation to resuscitation status record-keeping is underway, with CPR status now a formal part of the handover for each nursing shift.

Action Taken (AI summary) Specific guidance to check the oropharynx in patients with epistaxis and facial trauma has been added to the surgical SHO induction sessions. The case was discussed at the ENT M&M meeting and it was agreed to raise awareness of epistaxis in facial trauma in OMFS and ED teams managing them.

Action Taken (AI summary) The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on duty. The team has also been reminded of record-keeping obligations.

Action Taken (AI summary) Manchester University NHS Foundation Trust has implemented actions and recommendations arising from a Root Cause Analysis investigation, including training on the Trust’s new electronic patient record system (HIVE) which issues automated alerts for potential sepsis cases, and periodic audits to ensure appropriate recognition and timely treatment of sepsis.

Action Taken (AI summary) The Department of Health and Social Care reports that the Greater Manchester ICP developed a Co-Occurring Conditions team for system-wide training, and Tameside launched a Living Well Plus service for high-intensity A&E users; OHID has published guidance for commissioners; and national strategies include additional funding to improve treatment services for mental health and substance misuse.

Action Taken (AI summary) East of England Ambulance Service has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at hospitals in Norfolk to improve response times for critical patients, and shared a briefing for HM Coroners in relation to hospital handover delays. Spire Norwich Hospital has added wording to patient admission letters to ensure all patients are aware that the hospital does not have an on-site critical care unit, and has agreed a process with East of England Ambulance Service for clinician to clinician discussions regarding inter-provider transfers.

Action Taken (AI summary) East of England Ambulance Service is working with system partners and the Healthcare Safety Investigation Branch (HSIB) to manage call demand, has implemented daily system calls with stakeholders, and has implemented 'Category 1 drop and go' and 'Category 2 rapid release' projects at a local level in Norfolk. The hospital added wording to admission letters informing patients it does not have an on-site critical care unit. They agreed a process with EEAST for clinician-to-clinician discussions during delayed ambulance responses to share detailed patient information.