2024

Noted (AI summary) NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports.

Noted (AI summary) The organisation acknowledges receipt of the letter and clarifies the relationship between National Care Consortium and Pristine Care Group Ltd. The care home has implemented processes and protocols to address identified shortfalls, with auditing duties carried out by the senior management team. A CQC inspector reviewed the protocols and was happy with the improvements.

Noted (AI summary) NHS England outlines national standards for neonatal critical care units, references BAPM standards, notes NHS Trusts exercise their own policies for on-call response times, and states that University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board have been engaged on the concerns raised in the report. The British Association of Perinatal Medicine (BAPM) will send out a safety alert to its members and stakeholders drawing attention to recommendations about consultant cover for neonatal units. University Hospitals Sussex acknowledges that current on-call arrangements do not meet BAPM standards and is exploring options for a separate Neonatal Consultant on-call rota for the Princess Royal Hospital. They are approaching the Integrated Care Board (ICB) to consider externally reviewing current arrangements.

Noted (AI summary) The DHSC acknowledges the coroner's concerns, notes that the CQC has been informed and that actions have been taken by the Trust, and emphasizes the importance of patient safety and the new Patient Safety Incident Response Framework (PSIRF). Barts Health is reviewing its Bereavement policy to clarify guidance on the removal of tubes, lines, and devices, mandating they remain in place until after discussion with the medical examiner, decision on coronial referral, and issuance of the death certificate. They will also cascade learning from this incident and embed it within training.

Noted (AI summary) NHS England states that they do not endorse a particular STREAMing model nationally and that the STREAMing pathway in use by Medway Maritime Hospital does not have an undue prioritisation of chest pain and that the pathway would likely not have altered the outcome of the initial assessment in this case. They also note that all reports are reviewed by the Regulation 28 Working Group. The Royal College of Emergency Medicine states that they are unable to comment on the specific concerns raised as they are unfamiliar with the STREAMing model and notes existing guidance and work with NHS England on initial assessments. NICE acknowledges the concerns but states that the issues raised are outside of their remit, as they relate to a system produced by NHS England.

Noted (AI summary) Milton Keynes Council states that they adhere to a risk-based approach to highway maintenance, in line with national guidance, and that inspections did not reveal any actionable defect at the location. They will continue to fulfill their statutory obligations as the Highway Authority.

Noted (AI summary) The Department acknowledges the concerns raised, explains the multiple channels for patients to contact GP practices, and highlights existing regulations and CQC expectations related to patient safety and access to care. It also notes that NHS Greater Manchester ICB will be working with the practice to ensure digitised services meet national standards. SSP The Pike Practice has updated its automated email response across all SSP practices and is performing audits of email response times. The practice is also carrying out educational communications via social media, HR discussions with staff, and meetings with senior management.

Noted (AI summary) NHS England is reviewing its communications approach to alerting GP practices about medicine shortages and the Pharmacy and Medicines Optimisation Team is reviewing the use of AAIs and their supply. All reports received are discussed by the Regulation 28 Working Group. BSACI is developing an online allergy education platform for healthcare professionals and others, covering anaphylaxis recognition and management. The BSACI allergy action plans include difficulty swallowing as a manifestation of anaphylaxis and state "if in doubt, give adrenaline." The RCP will work with other colleges and societies to agree and support standards of care and education related to allergy, including updating standards for allergy accreditation and promoting multidisciplinary care. As a member of the EAGA, the RCP is working on the development of the UK National Allergy Strategy. The GDC will write to NICE to suggest they review anaphylaxis symptoms and guidance for dental professionals, and will consider changes to CPD requirements regarding medical emergencies as part of a review concluding in 2025. The GPhC acknowledges supply issues with adrenaline autoinjectors and highlights existing standards for pharmacy professionals, signposting other resources for safe AAI use and directing medicine supply inquiries to the DHSC. They offer a meeting with Hannah's family. The RCPCH will share information from the report with its members via a patient safety portal and for discussion with the Clinical Quality in Practice Committee, where further actions may be identified.

Noted (AI summary) The RCEM expresses condolences and refers to existing guidance for re-attendance, paediatric emergency care standards, educational material on Group A Streptococcus, a Learning Disabilities toolkit, and the Oliver McGowan training programme. They state that questions about electronic patient records are best directed to NHS England. The RCPCH will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal and will discuss the report with the RCPCH Clinical Quality in Practice Committee to identify further actions. The Royal Free London Hospital has provided training on deteriorating conditions in children, including the use of the Paediatric Early Warning Score and sepsis identification tools, and has re-familiarised staff with the SBAR communication tool. A nurse champion has been appointed to lead training and audits and a pathway has been implemented to ensure reattendees are seen by the next available doctor.

Noted (AI summary) Staffordshire County Council reviewed the road layout and collision history, consulted colleagues, and assessed traffic speed. They believe the existing safety features are sufficient and note a future bridge replacement proposal depends on funding.

Noted (AI summary) NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National Primary Care Team will consider GP awareness of alerting ambulance services to specific conditions; the ICB will take the circumstances surrounding Margaret’s death to their GP learning sessions and consider a system-wide safety alert. AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient addresses. NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, and accepting care plans and flags from providers until an automated solution is available. They have also established an ICB-wide group to improve flagging challenges.

Noted (AI summary) UKCPI expresses condolences and confirms that the laundry pouch packaging complies with GB CLP Regulation and industry PSP. They suggest that the packaging may have been left open or damaged. OPSS has spoken to the UKCPI, who are exploring a new awareness campaign for those with caring or safeguarding responsibilities, which OPSS will promote to local regulators. Sainsbury's states that their capsules already included a bittering agent and that the packaging adhered to A.I.S.E. guidelines. They have since changed their packaging to a cardboard box with a child-impeding closure, tested in line with AISE protocol. The HSE acknowledges the concerns regarding laundry tablet packaging and refers to existing regulations about the classification, labelling and packaging of hazardous substances, detailing specific requirements around outer and inner packaging.