2023

Noted (AI summary) NHS England acknowledges the concerns raised and notes the Root Cause Analysis Investigation Report by South Warwickshire University NHS Foundation Trust (SWFT). They also note that SWFT is reviewing referral mechanisms and circulating a safety practice alert and that all PFD reports are discussed by a working group. South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW) jointly reviewed communication and referral processes and completed several actions including a roundtable discussion, confirming a one-contact referral process, circulating a safety practice alert and sharing learning at governance meetings. University Hospitals Coventry and Warwickshire NHS Trust engaged with South Warwickshire University Hospitals (SWUFT) and have agreed an escalation process that provides a direct line of communication 24/7. They will also explore technological options to improve communication and share this with other providers across the System. The Department of Health and Social Care notes that the South Warwickshire University NHS Foundation Trust and the University Hospitals Coventry and Warwickshire NHS Trust have addressed the coroner's concerns. They also note that NHS England has replied and are sighted on the issues raised.

Noted (AI summary) Surrey Police acknowledges the PFD report but notes that no specific issues were raised in relation to their force, however they will share the findings amongst relevant teams. Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council clarify the purpose of the SCARF process and highlight existing crisis support services. A project group will be carrying out a detailed review of their cross-agency SCARF process. NHS England highlights the National Care Records Service (NCRS) and Shared Care Records, aiming for national interoperability between all Shared Care Records in England by March 2025 to improve information sharing.

Noted (AI summary) NHS Cambridgeshire and Peterborough Integrated Care Board have signposted all GPs working for the NHS within to guidance on detection of skin cancers, reminded them to refer any skin lesions where there is diagnostic uncertainty, and reminded all services that they commission in primary care that excised skin lesions should be sent routinely for histology. NHS England stated that the ICS have reminded all GPs within Cambridgeshire and Peterborough Integrated Care System of the guidance on skin cancers, shared the benign skin lesion policy, and reminded their NHS primary care commissioned dermatology services of the guidance on techniques and facilities for conducting minor surgery. The Department of Health and Social Care acknowledged the concerns and stated that NHS England has responded to the coroner in detail. They reiterated the importance of patient safety and the role of the Care Quality Commission and General Medical Council.

Noted (AI summary) NICE clarifies that it has not published a guideline on managing chickenpox, but it does publish a Clinical Knowledge Summary (CKS) on its website. They have shared the report with Agilio Software, the external company who develop the CKS. The Royal College of Paediatrics and Child Health (RCPCH) will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal. They are engaging with NHS England and the Patient Safety Commissioner on implementing Martha's Rule nationally and support the recommendation for a universal varicella vaccination programme.

Noted (AI summary) The North East Ambulance Service details their procedures for checking doors and alternative transport options, noting that welfare calls are prioritized for patients who are alone.