2025

Noted (AI summary) NHS England states that the Greater Manchester ICB has reconfigured the monitors such that when an ‘ECG leads off’ alarm is generated, the monitor will give the visual yellow flashing banner. If the alarm is acknowledged, the yellow banner will remain and the audio will re-alarm after three minutes if the ECG leads are still not connected, whereas previously the monitor would ‘blink’ only and would not alarm. Philips acknowledges the concerns, explains alarm configurations on its IntelliVue monitors, and states that the hospital has reset the "ECG Leads Off" alarm to the factory default. Philips says that they will continue to support customers with education and guidance to hospital staff on configuring alarms but does not propose further action to the default configuration of the devices at this time. The Department of Health and Social Care reports that Philips issued a Field Safety Notice for users of their IntelliVue line of Patient Monitors which highlights that alarm function is user reconfigurable, and should hence be confirmed in use to ensure it is not accidentally left in the ‘alarm off’ state. The MHRA has published the document on its gov.uk platform, ensuring users across the healthcare system have access to this information.

Noted (AI summary) The RCRP Strategic Partnership Board acknowledges the concerns and explains that Right Care: Right Person (RC:RP) is an internal process for directing calls to the most appropriate service. They state that they will discuss call transfer and external communications with partner agencies. The Deputy Mayor will further consider with relevant agencies the options that will best meet the needs of the public, recognising that NWAS would not have powers of entry and would have to call GMFRS in the described scenario. They wish to take the time to consider the various options that will best meet the needs of the public. The College of Policing explains that Right Care Right Person (RCRP) focuses on internal triage processes between agencies, not on directing the public to specific services when calling for emergency assistance. They state they will continue to monitor emerging themes and risks with partner agencies.

Noted (AI summary) The Trust provided additional training on ‘The Deteriorating Patient’ in 2022. Since September 2023, the Trust has introduced additional recommended courses and in June 2024, the ward received teaching sessions about NEWS2 and response. The MHRA outlines existing regulations and guidance concerning paracetamol labelling, prescribing information, and safety monitoring. They have liaised with NHSE regarding the ePRaSE tool. The Royal Pharmaceutical Society will consider how to raise awareness of issues around duplication of medicines in electronic prescribing systems through future communications and engagement with the pharmacy sector. Lewisham and Greenwich NHS Trust describes safety features in its iCare electronic prescribing system, including 'hard stops' and 'soft stops' for paracetamol prescriptions. The Trust have reviewed their IPS very recently and are participating in a leadership exercise on this topic. Oracle Health (formerly Cerner) states its Millennium prescribing system features are appropriate and functioning as designed, and will continue to review and monitor awareness of this functionality among its Trust clients. The decision on whether to take a particular code or configuration enhancement remains with the client.

Noted (AI summary) Sheffield Wednesday Football Club acknowledges the coroner's concerns, but emphasizes the robustness of their existing radio system and the positive findings of the inquest regarding their safety arrangements. They outline existing measures for steward training, communication, and system review.

Noted (AI summary) The International Academies of Emergency Dispatch conducted an independent case review and found the EMD to be compliant with protocol; they note that a delayed response was likely a factor in the poor outcome.