Manchester University NHS Foundation Trust

“MFT intends to formally communicate this to the external transport providers that support in the discharges of our patients”

“we have put in place processes to ensure that this does not happen again.”

“We are also reviewing our processes where a person is discharged from a Manchester hospital into an 'out of area' locality and if a safeguarding concern takes place on discharge”

“We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report”

“we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report”

“EMAS has subsequently contacted Manchester Royal Infirmary for a copy of the new policy, but this is not available to share at present. From previous learning EMAS do already contact the ward when a patient is going to be discharged into the evening to ensure that this is appropriate, as happened with this case. This will continue as a safeguard to patients until the policy is received from Manchester Royal Infirmary.”

“we have focused on the Human Factors of errors in clinical medicine and have engaged with our Human Factors Academy (HFA). This will support us to understand better the other factors at play which contribute to incorrect ECG interpretation; and which can be mitigated in the future. 1”

“We will remind all our PAs of the need to discuss patients for discharge with senior medical colleagues and reiterate to all junior medical staff and non-medical clinical practitioners, that it remains good practice to discuss cases with their seniors for learning and development.”

“The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine nurse staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and”

“The consent process for transplantation has been strengthened all along the listing pathway, and all recipients are specifically informed during the assessment about CMV infection and its effects, morbidity and mortality. If they are being offered transplantation with a CMV positive kidney when they are CMV negative, they are considered high risk for developing CMV infection. This is discussed prior to transplantation with the recipient during the consent process and specifically documented.”