2024

Noted (AI summary) An observational peer review was completed in August 2024 by a Consultant Cardiothoracic Radiologist at Cambridge University Hospitals, and the Trust received the written outcome report. An SOP for deterioration of patients following lung biopsy is in place, and an air embolism training module is now available. The British Thoracic Society will propose a patient safety alert to the NHSE Patient Safety Committee to ensure a timely and appropriate response to air embolism following invasive procedures. The Royal College of Physicians supports the British Thoracic Society recommendation of an NHS Patient Safety Alert to raise wider awareness of air embolus. The Royal College of Emergency Medicine intends to raise awareness of air embolism among members by re-issuing a case report and considering specific guidance on recognition and management on its eLearning platform. The Royal Society of Medicine has asked Presidents of relevant specialist sections to include the risks of air embolism and its management in upcoming educational events. The Patient Safety section will elevate the profile of air embolism risks at its Patient Safety Summit in November 2024. The Royal College of Surgeons of England will flag the risk of air embolism within their governance mechanisms for ATLS and CCrlSP and will draw attention to the risk with their membership through regular communications. The Royal College of Anaesthetists and Association of Anaesthetists confirm that air embolism risks are included in anaesthetists' training and guidelines. They highlight the Quick Reference Handbook for managing anaesthesia-related emergencies and the Anaesthesia Clinical Services Accreditation scheme standards. A standard operating procedure for managing a deteriorating patient after image-guided lung biopsy has been implemented. A consultant anaesthetist has confirmed that an air embolism training module is now available to all Royal College of Radiologists members, and a REAL talk has been scheduled.

Noted (AI summary) The Department of Transport acknowledges the coroner's concerns regarding cluster sites and GPS routing but states that decisions about highways maintenance and enforcement are the responsibility of local authorities and that drivers should prioritise road signage over GPS guidance. Cambridgeshire County Council plans to implement a 30mph speed limit (with 40mph buffer zones) on Puddock Road by the end of November 2024, conduct a traffic flow survey in early November 2024, and undertake informal engagement on road closure/restricted access, followed by a formal Traffic Regulation Order application and consultation.

Noted (AI summary) The Metropolitan Police Service will deliver learning to staff and officers highlighting the importance of strict location sharing and compliance with standard operating procedures. Surrey Police reviewed records of calls and concluded that calls were handled correctly and promptly passed to the MPS. They agree with MPS that there was no failure in communication between Surrey Police and MPS.

Noted (AI summary) Sunlight Care Group has updated policies, conducted a Serious Incident Review, and commenced a training program for staff. The training covers topics such as recognizing self-neglect, home safety, nutrition, and risk management, with a detailed schedule outlined in the response. The council has already completed a Safeguarding Adults Review referral and held a meeting with Sunlight Care, implementing a quality improvement plan and enhanced monitoring. They also plan further actions including a learning event with ASC, Sunlight Care and ELFT, a review of safeguarding procedures and training on implementing inquest lessons. The DHSC acknowledges the concerns raised in the report, referencing the Care Act 2014 and Mental Capacity Act. They highlight existing resources like the Care Workforce Pathway without committing to specific new actions. The Trust has increased time slots in the dressing clinic, staffed it with a substantive nurse, and will review with staff the need to proactively arrange professional meetings when they witness concerns. They also describe changes to wound care pathways.

Noted (AI summary) NHS England acknowledges concerns about oesophageal intubation and the PUMA guidelines and states they will clarify the future direction of the Never Events Framework. They also note that all PFD reports are discussed by a working group to share learnings. The organisations agree with the coroner's concerns and highlight their existing work, including the 'no trace = wrong place' campaign, endorsement of PUMA guidelines, and emphasis on capnography in anaesthesia standards. They also express support for unrecognised oesophageal intubation to be a nationally reportable incident. The RCEM expresses support for adequate staffing, multidisciplinary simulation training, equipment standardization, intubation checklists, and capnography use, referencing an existing framework for collaboration between Emergency Medicine and Intensive Care Medicine.

Noted (AI summary) The Secretary of State acknowledges the coroner's concerns regarding the Online Safety Act and its application to potentially harmful content on platforms like Amazon, but states that enforcement is the responsibility of the police and CPS. The response also clarifies the remit of the Ministry of Justice regarding the Suicide Act 1961.