2026

Action Planned (AI summary) Betsi Cadwaladr University Health Board is progressing work on developing an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance, under executive sponsorship.

Action Planned (AI summary) East Sussex Healthcare NHS Trust will implement measures for clinical teams to liaise with family members to understand how the patient typically expresses pain and what interventions have previously been effective, and a business case is being developed to explore additional support for the Learning Disability Nurse role.

Action Planned (AI summary) NHS England's regional colleagues have reached out to Derby and Derbyshire ICB, who advised that East Midlands Ambulance Service will be responding directly to the concerns raised, and that the Trust is reviewing Memorandums of Understanding and revising clinical presentation protocols. The Trust will continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD, work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management, and review its internal clinical guidance.

Action Planned (AI summary) The Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning, will monitor adherence with dietetic care planning in real time, is carrying out a therapeutic review of processes, and is seeking to develop an escalation process for out of hours periods.

Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS has worked with partners to develop a Sepsis Observation Safety Net, implemented enhanced clinical review processes prior to call transfer, and ceased manual ITK push transfers to NEMS. NEMS has stopped manually pushing calls, implemented a standardised Sepsis Observation Safety Net, and provided additional training and resources to clinicians; furthermore data sharing agreements are in place to share discharge summaries and admission avoidance alerts. The ICB facilitated a system wide After-Action Review, EMAS have stopped the ITK push of calls, a review and redefinition of the existing UCCH service specification has occurred, and analytics team have developed the ability to join up multiple data sets to understand patient journeys.

Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS clinicians now review all available information prior to transferring calls, and clinically assessed calls are no longer pushed to any EMAS Clinical Assessment Service (CAS). Manual ITK push transfers to NEMS have ceased. NEMS implemented changes to clinical practice and referral processes, including revised sepsis screening tools, enhanced clinical oversight, and improved information sharing with system partners. They have also invested in staff training and equipment to improve the management of complex patient presentations. The ICB facilitated a system-wide After-Action Review, reviewed and redefined the UCCH service specification, and developed the ability to join up multiple data sets to understand the patient journey across the pathway. They also committed to sharing PFD learning and assurance actions across multiple committees and processes.