Department of Health and Social Care

“the MHRA communicated advice on monitoring blood concentrations of clozapine and other antipsychotics in the August 2020 edition of Drug Safety Update', which is the MHRA's monthly newsletter for healthcare professionals about medicines safety.”

“a GM Discharge Pathway and good Discharge to Assess (D2A) system in place”

“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go”

“We must do all we can to learn from what happened to Mr [name redacted] and improve the safety and quality of NHS care and I expect the Stockport NHS Foundation Trust and its local system partners to reflect carefully on the findings of your investigation.”

“My officials have made enquiries with the Care Quality Commission (CQC), the independent regulator of quality, and NHS England and NHS Improvement (NHSEl) and | am aware that regulatory action was taken by the CQC following an inspection at Stepping Hill Hospital in January and February this year”

“The NHS published the Interim People Plan1 in June 2019 that sets out the long-term vision and immediate actions to meet the challenges of workforce supply, reform, culture and leadership. Publication of the final NHS People Plan has been deferred so that the NHS is able to devote its full operational effort to the COVID-19 response. However, when published, the final NHS People Plan will set out further actions to secure the NHS staff we need in the future.”

“increased midwifery staffing numbers by 10 full time equivalents and undertake a six monthly Board level review of midwifery staffing”

“we issued our revised guidance to the UK ambulance services in June 2019”

“the CQC continues to be in close contact with the Trust and will take regulatory action if it decides that it is necessary”

“England and NHS Improvement (NHSEI) have put in place an intensive programme of support at the Trust”

“The Trust must continue to strengthen its processes to learn from deaths and develop an open, learning culture for the safety of its patients”

“the Trust has developed its approach to engaging with families when unexpected deaths occur and to involve families in the investigation of these 2”

“the Trust Board is taking these matters very seriously and has welcomed the national support being provided.”

“Any service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi- Disciplinary Meeting with senior overview of the decision to discharge.”