2023

Action Taken (AI summary) Hereford Medical Group implemented a new process allowing clinicians to listen to phone calls when online forms are unavailable, changed the staff newsletter to include the most up to date waiting times for appointments, and will include a Mental Health focus session over the next month during regular training for GPs. A protected education time in January will also focus on triaging, including clinical considerations and the triage process and protocols.

Action Taken (AI summary) Nottinghamshire Healthcare NHS Foundation Trust has taken immediate actions including a teaching session on Psychogenic Polydipsia within the ‘Trustwide 2-day Physical healthcare Training’, sharing learning from Michelle’s inquest, and reviewing cases of polydipsia in secure settings. The Trustwide Nutrition and Hydration Policy is also under review to specifically reference psychogenic polydipsia.

Action Taken (AI summary) The Home Office has implemented new commissioning and handling processes and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from internal and external investigations, ensuring risks are managed consistently. They also use a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. An escalation process that highlights responses that have not been received within 20 days has also been introduced. Practice Plus Group has implemented weekly and fortnightly meetings between healthcare management and prison governors to improve communication between agencies. They have also clarified the established process regarding concerns for a prisoner's safety, where officers should inform a member of the healthcare team if they are presence. HMPPS has re-issued a notice to staff at HMP Belmarsh clarifying procedures for unlocking cell doors during the night state, emphasizing preservation of life takes precedence. Additionally, learning from probation-involved inquests will be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.

Action Taken (AI summary) Birmingham and Solihull Mental Health Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation, set up a project group to look at the risk assessment process, and completed a review of the risk management policy. Completion rates for risk assessment for CPA patients within community services have increased.

Action Taken (AI summary) NHS England worked with the MHRA to update the Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL) for Nitrofurantoin to emphasize the risk of respiratory symptoms. This was communicated to healthcare professionals via a MHRA Drug Safety Update and highlighted in an NHS England Patient Safety Case Study. The MHRA updated warnings in the product information for nitrofurantoin for both healthcare professionals and patients, highlighting the risk of pulmonary adverse drug reactions. They also published a Drug Safety Update bulletin to raise further awareness amongst healthcare professionals.

Action Taken (AI summary) EEAST is working with the integrated care system to reduce arrival to handover times, has implemented unscheduled care coordination, and has increased referrals into community teams. The government delivered over 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, scaled up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and provided £1.6 billion to support timely and effective discharge from hospital.

Action Taken (AI summary) CQC requested the Chief Coroner's Office to disseminate messaging to all coroners regarding notifications of inquests and Regulation 28 reports, including specific email addresses for submissions. The Chief Coroner's Office acceded to the CQC's request in December 2023.

Action Taken (AI summary) NHS England and local services have made strides in minimising staff turnover and foster effective communication and collaboration between CRHTT and Community Teams, with continuous training for CRHTT members. The government has also increased NHS spending on mental health and invested in the recruitment and retention of more mental health workers.

Action Taken (AI summary) The practice has implemented several reviews and changes to prescribing practices and supervision, including a new policy and flow chart for drug alerts, improved documentation, a new consultation booking system and training. An educational event was held to discuss recognition and management of psychotic depression.

Action Taken (AI summary) The trust has introduced a daily Safety Huddle on Balcombe Ward, is updating the Trust Medicines Management policy and competency assessment documentation, and is issuing a Medicines Governance Notice regarding bedside medication. Refresher education and training on medication administration has been completed and learning has been discussed with nursing staff.