NHS England

“The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre- pandemic levels”

“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”

“For those patients who can proceed to surgery, this will be scheduled to take place within the 36 hour timeframe to support compliance with NICE guidance. If this is not possible due to a theatre not being available, an urgent review of the entire trauma and elective lists that day will be undertaken. A clinical and operational discussion determines how the patient can be accommodated, and a plan is then devised. The detailed plan is then enacted with the approval of the Divisional Management Team”

“The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.”

“the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.”

“Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the”

“all health and social care providers registered with the Care Quality Commission (CQC) must ensure that their staff receive training on learning disabilities and autism appropriate to their role”

“The Trust takes these issues very seriously. The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process, the Trust have also planned to have psychologists join the L&D for reflective”

“The Trust takes these issues very seriously. The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process, the Trust have also planned to have psychologists join the L&D for reflective”

“the Home Office or the NPCC would be best placed to respond to specific concerns in this case”

“The NHS England Kent, Surrey and Sussex regional team will be convening a Performance Advisory Group (PAG) as part of NHS England » Responding to concerns procedures.”

“The NHS Frimley ICB will be carrying out a number of actions following the inquest. These include sharing the concerns raised with all GP practices in the Frimley area. The learning will focus particularly on the importance of good documentation in recording risk of suicide or self-harm following a consultation when someone has been assessed as having suicidal ideation or is at risk of acts of self-harm.”

“The team investigating and drafting this response have met with representatives from a variety of teams that cover this domain of healthcare. We have also ensured that they are aware of the new guidance on beds and cots 'Bed rails: Management and Safe Use .”

“£7 million for local areas to test ways to improve the quality of autism diagnostic pathways”

“We have begun to examine these unique identifiable records with a view to: 1) understanding the rationale and the validity of the diagnosis in these cases, in view of the potential for diagnostic confusion. 2) determining if and how the diagnosis has been shared and made clear in the records. 3) whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engaging with clinical teams proactively and acknowledge that this could possibly be”

“the CCG commissioned TEWV to provide mental health services for the population regardless of whether someone also has a diagnosis of a neuro developmental disorder/condition. The ICB have now had that contract novated to them upon the establishment of the ICB on 1 July 2022.”

“registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”

“investing £1.5 million into the development and trialling of autism training for staff working in adult inpatient mental health settings by March 2023”

“investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability”

“includes £40 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country.”

“The Department will continue to support and assure this work to progress against key actions, including ensuring better awareness of eating disorder training and continuing professional development.”

“we expect pharmacy owners to: - Make sure that their website and the websites of companies they work with are arranged so that a person cannot choose a prescription only medicine and its quantity before there has been an appropriate consultation with a prescriber”

“we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”

“We are also aware that our regulatory partners, including MHRA and the GPhC, share our concerns about the lack of regulatory oversight in this area.”

“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK's legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient's GP before prescribing.”

“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken: 1. Work has been undertaken on a focused area of learning known as a”

“Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability.”

“The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.”

“Our Head of Governance for 111 plans to publish a shared learning based on [the deceased]'s family's contacts with the 111 service before the end of January 2022.”

“It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.”

“SECAmb does not specify a field of experience such as A&E or urgent care because the range of medical conditions and situations with which we deal on a daily basis is so wide. Experience in a wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental health) helps us to accommodate the extremely diverse needs of our patients.”