Royal College of Physicians

“We will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of our ongoing monitoring and engagement with them.”

“NHS England has published a summary of existing guidance on the deployment of medical associate professions for NHS organisations. This guidance makes it clear that all staff should introduce themselves and their role clearly and be supported by their employer to do so.”

“RCEM issued a position statement in October 2024 regarding patients who may require a laparotomy [7]; this statement highlights that some patients are at greater risk of requiring surgery and part of this group includes the older person and those with cognitive impairment.”

“the Department notes that the report has been sent to a number of medical Royal Colleges and professional bodies relating to anaesthesia. We think these organisations are best placed to respond to points 6, 7 and 8 of your report which relate specifically to guidelines around anaesthesia therefore our response focuses on points 1 - 5 only.”

“We will consider the information you have provided and determine whether any further action is required either through our Outreach or fitness to practise process.”

“The Trust notes that the report has been sent to the national bodies and will embrace any changes recommended by them.”

“We will attempt to complete our initial review into the actions of Dr in around three months”

“The BOA will be taking this further. We produce BOAST documents (British Orthopaedic Association Standards) and will be setting up a short life working group involving haematology colleagues to see if it would be possible to produce relevant guidance on the management of such cases in the future.”

“Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase in the use of remote advice have proposed that standards are developed with respect to what elements of remote advice should be documented to ensure effectiveness and prevent harm.”

“The Trust has moved the handbook of medical emergencies, which includes guidance on the management of hyponatraemia, to the Trust intranet, which can be more easily accessed by staff. (See Recommendation 4 of the Action Plan). This was completed in August 2018.”

“the Trust will be ensuring that adherence to the policy for the Management of the Acutely Ii! Patient is monitored at the divisional Morbidity and Mortality meetings.”

“Recommendation 5 of the Action Plan sets out that; 'Desmopressin should be notified as a high risk drug that should not be discontinued without specialist advice.' The specialist providing the advice to discontinue the drug will ensure that there is a plan in place to reintroduce the drug at an appropriate time. This action has been implemented by the Medicines Management Committee with input from the pharmacy department.”

“The updated guidance on the management of hyponatraemia will set out the importance of ensuring that patients with hyponatraemia have regular monitoring of their fluid balance charts.”

“The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the r”

“The College believes that sound recording systems and well organised record-systems are fundamental to good general practice and communications with fellow healthcare professionals outside the practice. This expectation is set out in the section of the GP [name redacted] on”

“We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service.”