2024

Action Planned (AI summary) DHSC acknowledges ambulance response times are below standard and that the Health Secretary ordered an investigation into NHS performance and a 10-year reform plan. NHS England is taking action to improve performance including maintaining increased ambulance capacity, reducing handover delays, and increasing direct referrals into community services. Regional teams will review EMAS performance. The department will also consider the coroner's concerns when working with NHSE on expanding medicine responsibilities for healthcare professionals.

Action Planned (AI summary) NHS England is working at a national level to deliver the Long-Term Workforce Plan to address staffing shortages. They also mention plans for collaboration between Patient Safety and Digital Clinical Safety Teams to improve EPR implementations, and for GM ICB to improve the interface between secondary and tertiary care systems. NHS Greater Manchester acknowledges concerns about delays in cardiac services and highlights the GM Care Record. They will challenge leaders supporting digital transformation to improve the interface between secondary and tertiary care systems and share learnings in September 2024.

Action Planned (AI summary) The surgery plans to discuss the SOP during an education session, undertake quality improvement work on opioid prescribing (including patient reviews), and review the SOP in July 2025.

Action Planned (AI summary) The Department of Health and Social Care notes that NHS England is developing a Time Critical Medicines Safety Improvement Programme to identify opportunities for improvement and make recommendations on how to prevent harm to patients and that each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm.

Action Planned (AI summary) Digital Health and Care Wales is developing a business case for the introduction and deployment of mental health systems across health boards in NHS Wales, with a phased approach anticipated over a number of years. The Welsh government is also working to improve discharge arrangements and the quality of care and treatment planning through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. CTMUHB has made a dedicated psychological professional available for direct assessment and treatment in all three CRHTTs, eliminating the waiting list. They also contact people on the waiting list for psychological therapies in Local Primary Mental Health Support Services after two weeks and 6 months of waiting, using CORE-10 to monitor and escalate changes in clinical presentation or risk.

Action Planned (AI summary) MFT has developed a draft "Out of Hours Discharge Avoidance" SOP to manage delayed discharges, which is due to be presented for ratification at the MRI Quality and Safety Committee. They also intend to formally communicate this SOP to external transport providers once ratified across relevant sites. EMAS will continue to contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate. EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. The organisation amended inaccuracies in the Serious Incident Review (SIR) and reshared it with relevant safeguarding boards and the Manchester Foundation Trust Safeguarding Team. They have implemented a system to ensure investigations are completed in a timely manner and are reviewing processes for discharges to 'out of area' localities.

Action Planned (AI summary) Tesco initiated discussions with GMFRS and HFRS to establish a collaborative working group to review scenarios that may occur at remotely monitored petrol stations and identify potential operational or technological improvements. In the meantime, Tesco is working with GMFRS and HFRS to establish possible scenarios and identify if and where improvements can be made to mitigate any risk.

Action Planned (AI summary) BSI has passed the coroner's report to the responsible expert committees, who are considering amending the existing standard to include the recommendations that restrictors should withstand forces greater than the current British Standard and be tested to demonstrate this. The CQC has updated their ‘Learning From Safety Incidents’ webpage with a link directing providers to the Health Building Note 00-10 Part D: Windows and associated hardware. They have also committed to publish a note in their bulletin to providers in August 2024 to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. The CQC has published a note in its bulletin to providers highlighting the tragic loss of life following a deliberate attempt to bypass a window restrictor and reminding providers of the CQC’s ‘Learning From Safety Incidents’ webpage and updated the CQC website to reflect the Health Building Note published by NHS England.

Action Planned (AI summary) The Welsh Government outlines plans to introduce electronic prescribing and medicines administration (EPMA) systems in every hospital in Wales by the end of 2025, which will include timestamps for prescribing and administration events and task lists for medication administration. The Health Board is altering the Emergency Department Medication Card to prevent practitioners from writing "stat" and has sent a reminder to all clinicians regarding the Health Board's policy on clinical record keeping standards.