Care Quality Commission

“Following receipt of the request, Aria Care reached out to Shackleton's, our furniture supply partner seeking advice and guidance on riser/recliner chairs and the potential for purchase and supply of handsets that could be locked in a secure position and avoid unauthorised access and repositioning.”

“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”

“We have also reviewed the following documents: 1.) Summing up and conclusion from HM Coroner 2.) Reg 28 Coroner evidence BARNARD - 6. Full Inquest Additional 1 3.) Reg 28 Evidence from Coroner BARNARD - 3. Full Inquest Exhibits Medical Records. 4.) Regulation 28 report. 5.) Reg 28 Evidence form Coroner BARNARD - 1. Full Inquest Statements”

“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”

“The Council attaches a table in which it sets out, by column, its identification of what could be done better, learning from the circumstances of Mr [name redacted] death, the action it intends to take and the time-frame for that action.”

“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 cot used for [the deceased] during this admission was not a standard piece of equipment used by staff at TCT and they were unfamiliar with its use. This type of cot is no longer in use at TCT and all specialist cots have been replaced with equipment compliant with current bed standards. (BS EN 50637:2017 - Medical electrical equipment - Particular requirements for the basic safety and essential performance of medical beds for children).”

“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.”

“We will check at our next inspection that these changes have been embedded at St John's Nursing Home and that these were effectively minimising risks where these had been identified.”

“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”

“Please review the selection and monitoring of care home provision and care given by private care home providers who are funded by Devon Partnership Trust.”

“Review the selection and monitoring of care home provision and care given by private care home providers who are funded by Devon Partnership”