2023

Noted (AI summary) Barnet Enfield and Haringey Mental Health NHS Trust describes its usual procedures for when a client is not taking their medication as prescribed. They state that the expected standard is for the GP to be notified via email within 48 hours of the medical review when there are any changes to the client’s prescription or treatment plan.

Noted (AI summary) The practice reviewed the call recording and held a training afternoon on telephone triage and call handling. They highlighted the process of flagging calls for concern and discussed presentations of pulmonary emboli, and intend to audit details recorded by reception staff. NICE acknowledges the concerns, explains the guideline development process for venous thromboembolism prophylaxis, and notes that guidelines are not mandatory and are reviewed periodically.

Noted (AI summary) NHS England acknowledges concerns about understaffing/funding and the impact of weekend care. They describe national programs like the 7-Day Hospital Services Programme and the Delivery plan for recovering urgent and emergency care services, without committing to specific new actions. The Trust outlines the circumstances of the death and explains surgical prioritisation. They have introduced a dedicated fragility fracture theatre list 5 days per week and are reviewing the need for weekend provision.

Noted (AI summary) The response provides a summary of the inquest findings, including the deceased's medical history and the coroner's conclusion of a drug-related death. It notes that a report will be issued to the Limehouse Practice regarding medication prescribing and documentation practices. The Limehouse Practice will conduct SEA training for prescribers, review prescribing for patients at risk of dependence, document medication changes, and provide refresher training on EMIS prescribing function. They have contacted CGL/RESET for training and have improved internal communications.

Noted (AI summary) The Trust has invested in safe staffing levels, achieving a 1:8 nurse to patient ratio, and reduced Health Care Support Worker vacancies. They have also reviewed falls investigations and implemented additional training on falls risk assessments and enhanced supervision procedures. The response expresses condolences and acknowledges concerns about staffing levels and falls risk assessments. It states that staffing is a local responsibility, highlights CQC regulations and NICE guidelines, and notes the local trust's response.

Noted (AI summary) Welsh Ambulance Services NHS Trust does not propose further action directly, but is working with Aneurin Bevan University Health Board to implement additional measures in January 2024 to reduce conveyances to The Grange Hospital through direct admission to alternative sites, and the introduction of a new temporary facility. They also offer to meet to discuss the response in more detail. The Health Board acknowledges handover delays and that an ACA2 crewed ambulance could have attended. It states that reducing patient handovers is a focus and that the Chief Operating Officer and Clinical Executives are providing leadership to address the issue. NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat cover the diagnosis and early management of relevant symptoms, and they have not been asked to produce specific guidance on Group A streptococcus.

Noted (AI summary) West Midlands Ambulance Service acknowledged the ECG was abnormal and that policy wasn't followed; clinicians received a case review, participated in a Serious Incident process, completed reflective practice, and are scheduled for additional ECG/ACS training. Additional actions include updating policies and providing additional equipment/training to improve chest pain management and ECG interpretation. The Health and Care Professions Council acknowledges the concern but states that the individual in question is not registered with them, so the concerns do not fall within their remit for further investigation, but the individual's name has been added to a watchlist. The Health Services Safety Investigations Body is undertaking exploratory work regarding paramedic interpretation of ECGs in the community and will consider the scope for a formal investigation by the end of January 2024. The University of Wolverhampton will present case evidence to students, incorporate ECG interpretation into Objective Structured Clinical Examinations, liaise with coronary care units for anonymised ECG readings, add an ECG interpretation workbook to the virtual learning environment, and organise continuing professional development ECG masterclasses. The CQC has reviewed WMAS's actions following the death and found no evidence of provider-level failings, although they identified concerns regarding the timeliness of addressing the training needs of staff involved. The training needs of one staff member have been addressed, and the second staff member's training will be met upon their return to work.