2024

Noted (AI summary) NHS England expresses condolences and states that concerns have been listened to and reflected upon. They highlight the remit of other organisations (NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust) regarding some of the concerns, and reference workstreams to increase ambulance capacity and improvements to Tameside's ED. They also note the discussion of PFD reports by their Regulation 28 Working Group to share learnings.

Noted (AI summary) NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.

Noted (AI summary) NHS Frimley ICB organised a cross-system meeting across the South-East region to discuss the issues raised in the report and will be writing to NHS England about this case. The response is also being shared within relevant system and regional groups. NHS Frimley ICB organised a cross-system meeting across the South-East region to discuss the issues raised in the report and will be writing to NHS England about this case. The response is also being shared within relevant system and regional groups. The National Pharmacy Association will review their existing guidance and consider how to refine it, and raise awareness of the issue with Member pharmacies, and raise the matter with the sector-wide Patient Safety Group. Community Pharmacy Thames Valley expresses sympathy and notes that dispensing medication falls under a national contract, and has escalated the concerns to Frimley ICB and Community Pharmacy England and requested an anonymised case study to raise awareness. The General Pharmaceutical Council acknowledges the concerns and refers to existing guidance on person-centered care, reasonable adjustments for patients with cognitive impairment, and the use of MCAs. They will consider how to further raise awareness of these issues. The Specialist Pharmacy Service (SPS) outlines currently available information on the management of adherence and use of medicines compliance aids and suggests changes that may help prevent future deaths, while highlighting existing resources. Community Pharmacy England will raise the concern about clearly identifying MCAs in multi-person households with the RPS and CPPSG and ask them to consider additional guidance. They will also make community pharmacy owners aware of the specific risk and actions will be taken in the autumn of this year. Slough Pharmacy has amended their processes to include removing each tray from packaging and double-checking with the patient and provides a different brand of trays with totally different packaging to any households that involve more than one person with trays. The MHRA believes the concerns relate to the dispensing process and are better addressed by the General Pharmaceutical Council.

Noted (AI summary) NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and outlines NHS England's support for Trusts in developing electronic patient records and the CQC's process for reviewing incidents. The CQC has reached out to the Trust requesting information on this death. The Trust has added a prompt to both EPRs to each clerking form to prompt the user to check the patient's SCR, reviewed and amended the training scripts for both EPRs, implemented a new quick reference guide covering how the SCR can be accessed and includes a link to NHSE information and eLearning/Assessment via the new NCRS section on the Digital Services Hub, and the Renal team have already developed alert cards to be given to patients who have Tubulointerstitial Nephritis (TIN).

Noted (AI summary) NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere. CYP staff will be reminded that a referral ought to be made, staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. Norfolk and Waveney ICB states that they have reviewed their Mental Health Individual Funding Request records and have not been able to identify any Individual Funding Request being made to them on behalf of Ms Madden, for Schema-based Cognitive Behavioral Therapy. Suffolk Constabulary notes the concerns raised but states that they conduct their own risk assessments when delivering Claire’s Law disclosures, which would include the wellbeing of the recipient of that disclosure and the delivery was conducted in accordance with policy and appropriate aftercare. The ICB will work with partners to ensure that learning and action is taken forward from this case, and the Trust has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. The Home Office acknowledges receipt of the report and restates commitment but describes no specific actions taken or planned.

Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.

Noted (AI summary) The hospital states it does not provide a 24/7 emergency service for specialist interventional radiology for embolization, this is a specialised service commissioned by NHS England; The hospital states that the regulation 28 notice should be addressed to NHS England as the service commissioner. NHS England acknowledges the concerns regarding out-of-hours interventional radiology at Dorset County Hospital, but states a full service would likely be unsustainable. They believe the concerns are more appropriate for the Trusts to address and are seeking further details, while also highlighting national work on PFD reports.

Noted (AI summary) NHS England acknowledges the concerns about mental health bed shortages and highlights ongoing investment in mental health services and the Better Care Fund. They are seeking further information from the North West region and will discuss the report at the Regulation 28 Working Group.