2023

Noted (AI summary) Dorset Council confirms that they ensure health is consulted on medication, its use, storage and any risks at assessment and review points. They also confirm written confirmation from Health in writing of any known risks linked to the use of specific medications for named individuals and how to safely manage these is obtained. The learning recommended from the action plan was shared with relevant managers in February 2023. The ICB notes that patient information is accessible via the Dorset Care Record (DCR) and that this gentleman has had a DCR since February 2018, which has been accessed by health and social care staff. They have shared the findings with the relevant teams to inform any future improvements to the DCR.

Noted (AI summary) NHS England notes the Trust's strengthened training and improvement work following the death. They highlight ongoing work nationally on maternity services, and dissemination of learning through the Regulation 28 Working Group. The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. The CQC has requested information from University Hospitals Sussex NHS Foundation Trust regarding actions taken and intended in response to the report. They will monitor the Trust's progress and compliance, including implementation of the national medical examiner system and processes for equipment isolation. St Richard's Hospital describes their Maternity Improvement Program developed with the Maternity Safety Support Program and the achievement of year 4 requirements of the Clinical Negligence Scheme for Trusts (CNST). They have also reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB. Health Education England expresses condolences but states the concerns fall outside its remit, highlighting work on patient safety training and collaboration on broader NHS improvements.