Delayed Recognition of Deterioration

That part of the basic training course for new prison officers which focuses on the development of their inter-personal skills should be reviewed in the light of this report and the lessons to be learned from Zahid’s murder. In particular, two of the key attributes required of the prison officer should be stressed. They are the ability to...

Wing officers should be reminded of the need to call for a review of an assessment when the necessity for one is triggered by some occurrence which might affect the prisoner’s emotional well-being.

All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, to ensure consistency and implementation across all neonatal units at speed. By 31 March 2027, NHS England should...

Key process variables, as determined by the Safety Case, should be monitored and controllable from the Control Room (para 18.36).

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy themselves that the services they are commissioning meet the particular needs of the group of people harmed by...

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, rather than a more junior member of staff, wherever practicable

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: fibroscan technology should be used for liver imaging, rather than alternatives

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: where there is any uncertainty about whether a patient has fibrosis they should receive the same care

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: those who have fibrosis should receive the same care

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis