2023

Noted (AI summary) NHS England acknowledges the need for better guidance on managing oesophageal stenting and will work with AUGIS and NICE to develop national, evidence-based advice. The Greater Manchester Cancer Alliance will develop a clear pathway for the management of oesophageal stenting. NICE acknowledges the concerns about oesophageal strictures and limited guidance and will log the report and consider further the concerns regarding contraindications for stenting.

Noted (AI summary) Dorset Police are launching Project Synergy to improve their investigative operating model and increase the resilience and wellbeing of investigative teams. They are recruiting a Detective Chief Superintendent to lead the project, which includes forming investigative hubs and introducing investigation support officers. The Ministry of Justice acknowledges the coroner's recommendations and highlights existing and planned government actions related to funding victim support services, improving SARC provisions, and implementing the Victims and Prisoners Bill. Response notes Chief Constable will address concerns about rape investigation caseload. Network Rail has instructed the raising of the parapet at Menacuddle Hill/North Street Bridge to a minimum of 1250mm above adjacent surface level, with an additional course of stonework from an existing minimum height of 990mm. The current timescale for completion of the project is one year from instruction. Cornwall Council acknowledges the complexity of funding for sexual violence recovery services and states that there is no record of Ms. Dolamore having contact with the Council's children's or adult social care services. It describes the Early Help Hub and training offered to professionals.

Noted (AI summary) The Trust introduced a new e-RS system for managing referrals, a consultant-led advice and guidance service for GPs, and consultant-led triage for outpatient clinic referrals. They are also working to manage demand across sites and recruiting substantive consultant neurologists. NHS England acknowledges the concerns, notes the Trust's actions to improve neurology capacity, and mentions the NHS Long Term Workforce Plan to address national shortages. They also state that all PFD reports are discussed by the Regulation 28 Working Group to share learnings.

Noted (AI summary) Sheffield Children's NHS Foundation Trust has improved induction training for junior doctors, providing information on when to escalate concerns to senior staff, particularly regarding reattenders, fever, chicken pox and sepsis. They have reminded primary care of the current referral system and will ensure patients arriving with GP letters are seen by the appropriate team. Sheffield Children's NHS Foundation Trust CEO expressed apologies to the family and outlined the various actions taken, including a meeting with the family and a presentation to the Trust Board to emphasize learnings from the case.

Noted (AI summary) West Midlands Ambulance Service acknowledges the concerns and explains that they use NHS Pathways for triage, as required by Department of Health guidelines. They also describe their clinical validation team's review of category 3 and 4 patients and regular clinical audits.

Noted (AI summary) NICE acknowledges the report but states that responsibility for the BNF content lies with BMJ Group and the Royal Pharmaceutical Society, so they cannot comment on the concerns raised. BNF Publications will use communications, including a newsletter and social media, to remind users how to find drug class information within content, including monographs and treatment summaries.

Noted (AI summary) The practice discussed the case at a partners meeting and raised a significant event to discuss with the wider team, but concluded that no further action could be taken because the patient did not complete the advised tests.

Noted (AI summary) NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat should be considered. They highlight that a specific guideline on Group A streptococcus has not been requested and that rapid tests were not recommended for routine adoption. MFT expresses concern for better clinician awareness of GAS and its management, and has liaised with relevant bodies to raise their concerns. They recommend the development of comprehensive, nationwide guidance for clinicians on GAS, similar to existing guidance for meningococcal disease. The Department of Health and Social Care highlights NHS England's interim clinical guidance on Group A Streptococcus and a public campaign to inform parents about symptoms. They also mention plans to implement Martha's Rule to allow rapid review of deteriorating patients. The RCPCH has shared information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and will share the information for discussion with the RCPCH Clinical Quality in Practice group in October.

Noted (AI summary) The council explains existing processes for safeguarding and quality monitoring of care providers, stating they are satisfied that appropriate assurances are undertaken to see whether action does need to be taken by the wider council as a result of an individual’s death.

Noted (AI summary) The Trust provides a chronology of events regarding a prednisolone dosage reduction error and states that the treating and discharging physicians were aware of the dosage error and that it caused no harm to Mr. Roberts, therefore requiring no action by the GP. BNF Publications will add "diverticular disease (increased risk of diverticular perforation)" to the "Cautions" section of all corticosteroid monographs in the BNF, actioned for the August online monthly update.

Noted (AI summary) NHS England has worked with South London and Maudsley NHS Foundation Trust, who have identified dual diagnosis leads, established a CAMHS Dual Diagnosis forum, incorporated learning from Serious Incidents into team meetings, and are holding briefing sessions on AUDIT completion requirements. All reports received are discussed by the Regulation 28 Working Group. The Department of Health and Social Care acknowledges the concerns and refers to NHS England's response. It also mentions national initiatives for mental health and substance misuse services, including increased funding and commissioning quality standards.