2024

Noted (AI summary) NHS England highlights the Suicide Prevention Strategy and guidance to improve the culture of care for mental health inpatient services. Oxleas has designed a clinical risk training workshop, and participates in the Royal College of Psychiatrists’ Culture of Care Programme. The Department acknowledges concerns about the use of risk assessment tools and refers to NICE guidance and the 5-year Suicide Prevention Strategy for England. It highlights NHS England's work to improve risk management within mental health services, including guidance published in April 2024. The Trust will issue a blue light bulletin reminding clinical staff to update risk assessment documents, and will audit risk assessments using the 'Tendable' system. The Trust will also work with the National Culture of Care team to adapt the risk assessment and formulation tool.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the matters are primarily local issues for Barts Health NHS Foundation Trust to address. Barts Health acknowledges documentation issues and is planning several actions including consultant re-induction, audits, training on capacity assessment and sedation, and recruitment of a learning from deaths lead.

Noted (AI summary) BOC apologizes for the late response, explains the regulatory background, and requests an extension to provide further information. BOC claims they did not receive the report until late June.

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) NHS England expresses condolences and notes the concerns, but states that treatment for substance misuse is not within their remit. They highlight the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The Department acknowledges concerns about residential and detoxification facilities for young people, but states that inpatient detoxification is rare and should be managed by community services with hospital support. They highlight existing funding and support for local authorities to improve drug and alcohol treatment, and will keep service models under review.

Noted (AI summary) Surrey County Council acknowledges the coroner's concerns regarding vegetation encroachment and inspection frequency. They state that pavements are for pedestrians, not cyclists, and that the inspection regime is in line with their responsibilities and national guidance. They will, however, remind the inspection team to consider the risk to vulnerable users posed by debris.