2024

Noted (AI summary) The HSE acknowledges the coroner's concerns regarding welfare provision and workplace transport safety on construction sites, but asserts that existing legislation and guidance are sufficient and well-known within the industry. They will continue to raise awareness through stakeholder engagement and inspections.

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 Department of Health and Social Care acknowledges concerns about the investigation and governance processes at Barts Health NHS Foundation Trust following a patient fall. They mention the PSIRF, which became a contractual obligation for all Trusts from April 1, 2024, and that the CQC will be discussing the PSIRF in upcoming meetings with the Trust.