Worcestershire Acute Hospitals NHS Trust

“i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.”

“ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions”

“iii. The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS)”

“ii. Therefore, each division will undertake local regular audits, to check compliance with signing prescription charts”

“iii. Divisions will provide monthly VTE compliance reports to the Improving Safety Action Group (ISAG)”

“At the time of the incident, there was no policy in place for the management of medical outliers. In the action plan of the report the Chief Medical Officer (CMO) has an action relating to the review of a patient outlier policy and to taking over patient care. These actions are almost completed. Meetings were held between the senior clinical leaders and the Chief Medical Officer on 11th October 2024 and the 4th November to review the policy. The policy has been agreed and will be shared through”

“The Trust is compliant with NICE Guidance for falls risk assessment.”

“There will be a Lesson of the week around what constitutes both o hosiery and mechanical prophylaxis, and it will be reiterated to staff that they must sign the prescription chart to confirm that this prophylaxis is on/in place”

“Streamline and standardise Urology MDT processes to facilitate appropriate time to discuss cases fully.”

“We note your suggestion that the issues raised in your report should be considered in the development of our new guideline on adrenal insufficiency, particularly that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress.”

“Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk”

“recommend that all health and care providers ensure their organization has put processes in place to ensure the four actions on the National Patient Safety Alert have been addressed.”

“system for reporting and monitoring of serious incidents across England) and the revised terms of reference for the investigation to include the issues that you have identified. The revised report is now being reviewed independently of the clinical division responsible for the care delivery, by my Deputy Chief Medical Officer, and will be shared with [the deceased]'s family and with our Integrated Care Board by 7th October”

“[name redacted]. You raised 4 matters of concern. 1. You've invited the Trust to consider standardising the handover process across the hospital and to put in place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised.”