2025

Noted (AI summary) NHS England highlights existing functionalities such as the National Care Records Service (NCRS) and the SystmOne out-of-hours system that enable access to patient's Summary Care Record (SCR). They also note that Holderness Health migrated from EMIS to TPP SystmOne with GP Connect enabled to improve interoperability. Holderness Health confirms it migrated to TPP SystmOne with GP Connect enabled for interoperability, but the patient's surgery was 14 years ago and not considered a significant active problem. The CQC contacted the GP practice and Out of Hours provider to establish circumstances and intended actions. They state they ensure that they look closely at how providers deal with incoming correspondence, coding, and sharing of information during inspections, and were satisfied with the significant event analysis undertaken. The RCGP will highlight the case to their health informatics group to influence discussions with NHS England and will also highlight the concerns to The Professional Record Standards Body (PRSB).

Noted (AI summary) The Trust will appoint a consultant haematologist with oversight over the stem cell lab and investigations and work up of patients, and are entering discussions with NHSBT to create a joint post. They are also identifying funding at UHB by job planning review across the department. The DHSC expects NHS Trusts to review their staffing levels and notes existing regulations regarding staffing. They also note that they expect a response from the named Trust and Integrated Care Service.

Noted (AI summary) NHS England is developing a Reasonable Adjustment Digital Flag to record information about patients, including if they are autistic or have a learning disability, and their reasonable adjustment needs. The RCEM highlights existing resources such as the Learning Disabilities Toolkit and involvement in the development of the ED version of the national paediatric early warning system (nPEWS). They feel unable to comment on inpatient care and state provision of learning disability nurses is outside their remit. CQC acknowledges the concerns but states that commenting on the specific guidance is outside of their regulatory scope. They are reviewing the case in line with their incident guidelines. The Trust is developing a Learning Disability Admission Checklist to provide prompts for staff in Emergency Departments and establish a system to record reasonable adjustments, planned for Quarter 3, 2025. RCPCH's revised Facing the Future: Emergency Care Standards will be published in Autumn 2025 and shared with relevant professionals, and will include a standard on EDs having a lead professional for CYP with complex needs and access to advice from a Learning Disability Liaison Nurse. The Department highlights the upcoming 10-Year Health Plan which will improve awareness of learning disability and autism within the health and social care system. It also references Martha's Rule which gives patients and their families the right to initiate a rapid review of their case.

Noted (AI summary) The council disputes the coroner's concern that its staff could not access records, stating that the records were available, and a review of care arrangements was carried out with awareness of the assessment. It also states that its Careline service acted upon learning from the events leading up to the deaths of Mr and Mrs Cleall.