2022

Action Planned (AI summary) NHS Greater Manchester will present learning from the case to the Greater Manchester System Quality Group and cascade shared learning to professionals through relevant governance and learning forums; an action plan is attached to the response.

Action Planned (AI summary) Barnsley Hospital and South West Yorkshire Partnership are improving communication and referral processes, clarifying roles and responsibilities, and creating a protocol detailing operational delivery of a safe pathway, including clarifying consent and treatment responsibilities.

Action Planned (AI summary) HM Prison and Probation Service rolled out ACCT version 6 across the prison estate and has produced and delivered training materials to support staff understanding. Fifteen staff members received the new training module, and the Governor has issued guidance on risk identification. The Governor has also requested that bank nurses are not deployed in the reception area of the prison. Swansea Bay University Hospital will ringfence two slots per ACCT training session for Health Board staff and will roster health staff to attend ACCT Awareness training as a priority. Health Board bank staff will no longer undertake the reception or screening function unless they are key trained.

Action Planned (AI summary) LCC will review the format of its overview document in line with the adoption of a strength based approach framework, which is planned to be rolled out across all Adult Social Care teams within the next 18 months. LCC have agreed to meet with and will continue to work with the Trusts in the future. BTHFT will collaborate with LSCFT and LCC to examine LSCFT's Admission, Discharge and Transfer of Care Policy and Procedure, to ensure that all relevant information, including suicide risk, is known, managed and communicated. A Joint Mental Health Governance Committee will meet quarterly to support the delivery and development of high quality care to patients with psychological and psychiatric needs. Nightingale's has implemented a new pre-admissions checklist covering relevant assessments, and will no longer admit residents with a similar history to Ms Stringer without 1:1 care. All staff receive training to facilitate communication with residents.

Action Planned (AI summary) The Department of Health and Social Care highlights existing support for pharmacists in General Practice via Primary Care Networks (PCNs) and the Additional Roles Reimbursement Scheme (ARRS). It also mentions the National Overprescribing Review and its implementation program, along with the role of Integrated Care Boards (ICBs) in commissioning specialist pain clinics. Donneybrook Medical Centre has categorised and prioritised patients receiving repeat prescriptions of multiple analgesics with assistance from the Medicines Optimisation Team. A plan has been put in place to introduce a limitation on how many months prescriptions can be given before a patient's next review and safety netting has been put in place to ensure the various risk groups will always be reviewed going forward.

Action Planned (AI summary) NHS England issued a national letter in February 2022 emphasizing the need to address harm caused by handover delays, followed by meetings with systems to develop plans. Avoidable conveyance rates to Emergency Departments have decreased. All Reports to Prevent Future Deaths are discussed by a working group to share learnings and insights. The government has allocated £150 million of additional system funding for ambulance service pressures in 2022/23 and has tendered a procurement contract for auxiliary ambulance services. Local health and social care partners are using additional action to support discharge and improve patient flow and £450 million was invested to upgrade A&E facilities in 2020/21. NHS Birmingham and Solihull are implementing several initiatives to improve patient flow, including the development of virtual wards to facilitate early discharge and admission avoidance, with a target of 340 virtual ward beds by April 2024. They are also holding daily meetings to review mental health attendances and admissions, and opened an All Age Urgent Care mental health centre.

Action Planned (AI summary) Planning and Housing Cornwall Council is expediting the application for tree works, including internal consultations, with a decision expected before the end of the month; they have also scheduled a meeting for consultation. Sailors Creek CIC hand-delivered letters, posted safety notices, removed mooring ropes from trees, held a site meeting with concerned parties, and adapted their risk assessment and safety brief. They have also implemented a temporary system for positioning moored boats further into the creek, and plan to replant trees and develop a tree management plan by the end of September 2022, and complete the mooring chain along the length of the beach by the end of 2022.

Action Planned (AI summary) Balfour Beatty Living Places reports that, following consultation with Herefordshire Council, vegetation will be removed to increase sight lines to 160 meters, bi-annual clearance around the VRS barrier will be carried out, and a Traffic Regulation Order review of the speed limit is underway with a view to reducing it to 50mph, with completion hoped within 9 months. Herefordshire Council will consult on lowering the speed limit to 50mph and will review signing and lining along the bypass, implementing any improvements prior to March 2023, likely to include pedestrian warning signs on each approach to the three existing locations where public rights of way cross the bypass.