2023

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.

Noted (AI summary) NHS England is implementing improvements to the CYMPH inpatient pathway, aiming to reduce out-of-area placements and move towards community-based care; they are also developing a national admission protocol for children and young people with multi-agency partners. The Department of Health and Social Care acknowledges the concerns and notes NHS England's response and approach to reduce reliance on inpatient mental health beds, moving towards community-based care.

Noted (AI summary) NIVAS plans to publish guidelines in 2024 concerning the use of real time ultrasound guidance for central venous catheter insertion and the identification and management of inadvertent arterial puncture. They will also give the subject prominence at their annual conference in June 2024. The Association of Anaesthetists, Royal College of Anaesthetists, Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) will ensure that updated "Safe Vascular Access" guidance has more explicit recommendations for checking CVC placement. The ICS is also developing a guideline for managing inadvertent arterial puncture during CVC insertion. NICE acknowledges the concerns but states that existing National safety standards for invasive procedures (NatSSIPs), ICS CVC Insertion Safety Checklist 2023, and AAGBI guidance already provide recommendations, and they do not consider that further NICE guidance would add to existing national recommendations. The Department of Health and Social Care acknowledges concerns about the absence of a national policy on CVC placement, but states that existing NICE guidance and national safety standards should inform local standards. They do not consider further action is needed at this time as the clinician departed from existing national recommendations, NICE guidelines and Trust policy.

Noted (AI summary) The London Ambulance Service conducted a clinical review, stating that naloxone was not mandated in this instance. They highlight existing support for naloxone administration and offer to discuss ongoing work to improve cardiac arrest survival in London.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and outlines actions being taken by NHS England and EEAST to improve ambulance response times, including increased recruitment, clinical triage of calls, and the establishment of an Unscheduled Care Coordination Hub.

Noted (AI summary) DWP expresses condolences and outlines existing support and training for staff regarding vulnerable claimants, but does not commit to new actions. They state comprehensive guidance and a six-point plan are in place to support customers who discuss or imply that they intend to harm themselves.

Noted (AI summary) England Ice Hockey along with Ice Hockey UK (IHUK) and Scottish Ice Hockey (SIH), confirm the mandating of neck laceration protectors which comes into effect from 1st January 2024. The EIHL will mandate the use of neckguards for all players from 1 January 2024 in training and games, and a temporary rule change has been put in place to sanction non-compliance pending the provision of the full rule change from the IIHF. Ice Hockey UK describes its role as the national governing body and notes that the IIHF has mandated neck guards at all levels of competition. They state that IHUK mandated neck guards for Senior Men and Women with immediate effect on 30 October 2023, in addition to the existing mandate for the U16, U18 and U20 categories. England Ice Hockey provides information about regulations around neck laceration protection and the governance structure of Ice Hockey in the UK, but does not commit to specific actions beyond what is already recommended.

Noted (AI summary) NHS England outlines national guidance related to pressure ulcer prevention and refers to ongoing work as part of the National Patient Safety Strategy, but defers to the Trust regarding the specifics of service provision at Royal Stoke University Hospital. University Hospitals of North Midlands will continue to monitor the timeliness of pressure ulcer risk assessments and review referral criteria for the Tissue Viability Team, subsequently monitoring referral to response times.