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Recommendations Adults with a learning disability should be supported to take up annual health checks. Adults with a learning disability should be supported to attend a dentist for regular check ups. Social workers, as part of their annual review of placements, must check that individuals are receiving dental checks. All Primary Care Services in Hampshire are provided with information and web links for the National Patient Safety Agency (NPSA) ‘Ensuring safer practice for adults with learning disabilities who have dysphagia’. Health Commissioners ensure that there is sufficient Speech and Language Therapy resource within the community to respond to requests for assessment of learning disability clients identified as at risk of choking. The consent of the person with learning disability must be obtained before any medical investigation or assessment is carried out. All services providing for clients with a learning disability should use an Eating and Drinking Difficulties Screening Tool, which will indicate whether a choking risk exists and a referral to the GP is needed. All services providing for clients with a learning disability, who have a known risk of choking, should use the appropriate documentation in order to ensure the appropriate referrals are made. All Services providing for clients with a learning disability should ensure that they follow the instructions provided by the Speech and Language Therapist following an assessment. All services providing for clients with a learning Disability who are at risk of choking as a result of challenging behaviour or deliberate self- harm, should refer the individual to the Learning Disability Health Team for a formal assessment. If staff or carers identify that someone is at risk of choking from food or other objects in their mouth, a Mental Capacity Act assessment needs to be considered to support appropriate decision making. If clients, as a result of their behaviours and the consequent risk of choking, are prevented from accessing areas within a residential setting then an application should be considered from the care provider to the Supervising Authority (Local Authority) under the Mental Capacity Act Deprivation of Liberty Safeguards. If staff or carers identify that someone is at risk of choking, they must consider a referral to an advocacy organisation for an advocate to support the person with decision making in relation to eating and drinking plans. All carers and staff should be involved in the care planning process for people at risk of choking, particularly those who will be implementing the plan. Staff should be aware of the consequences of not following an agreed eating and drinking care plan. Care plans to support people at high risk of choking should be reviewed at least every 6 months or after any change in the person’s health or care. Staff induction training in all learning disabilities settings should include choking recognition and First Aid treatment of choking. All trainers to increase the emphasis on responding to choking incidents in First Aid training for services that provide care for people with learning disabilities. In line with the NPSA recommendation, regular practices or drills for staff around responding to a choking incident should be carried out as part of First Aid response training. The Group recommend a standard training matrix which should be used by all those providing care for those with a learning disability. The four Hampshire Safeguarding Adults Boards should seek to influence the Department of Health to consider a national data collection about choking deaths in people with a learning disability in order to understand the problem and guide improved practice. All Primary Care Services in Hampshire are sent the NPSA Learning Disability Dysphagia Protocols for GPs. The four Hampshire Safeguarding Adults Boards undertake a communications campaign to raise awareness around the issues of choking. A ‘Health passport’ is developed for every person with a learning disability to ensure that information around health risks including risk of choking is available to be shared between providers, with the person’s consent. All choking incidents involving people with a learning disability should be reported and investigated appropriately.

The guidance covers the following areas: What is infant mental health? Why does infant mental health matter? What are specialised parent-infant relationships teams? What infant mental health provision exists in the UK? Who needs infant mental health support? What impact has COVID-19 had on infant mental health?

CQUIN.pptx CQUIN.pdf

Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.

This document explains how patients are informed, involved and consulted in the development, improvement and delivery of health and care services.