2.12
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.12
Recommendation · source text
Following a CPA review if there are any significant changes in a patient’s risk management, support needs or medication the care coordinator should arrange as soon as possible to meet with the patient’s primary care service so that the patient’s records can be updated and any plans implemented.
2.13
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.13
Recommendation · source text
Where there is a planned transfer of a patient between NHS Trusts the responsible clinician must ensure, wherever possible, that the transfer of medical records is completed before they accept responsibility for the patient’s care.
2.14
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.14
Recommendation · source text
A full review of a patient’s historical medical notes must be undertaken by both inpatient and community services as part of their initial clinical and risk assessment.
2.15
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.15
Recommendation · source text
In order to evaluate the effectiveness of Solent NHS Trust’s Protocol for Receiving and Referring Transfers of Care an audit should be undertaken of a number of individual cases where this protocol has been utilised.
2.16
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.16
Recommendation · source text
Solent NHS Trust revised risk assessment form should have separate sections for historical, current and ongoing risk factors. Each risk factor identified should be cross-referenced in the narrative section. Triggers and protective and contributory factors should be clearly identified for every area of risk.
2.17
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.17
Recommendation · source text
Risk information should only be documented in one location within Solent NHS Trust’s patient records system.
2.18
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.18
Recommendation · source text
Consideration should be given during discharge and CPA planning to apply for Personalised Budgets or Direct Payments to fund additional care and support needs.
2.19
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.19
Recommendation · source text
Risk assessments and support plans should always be identifying and considering a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention.
2.20
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.20
Recommendation · source text
Serious Incident Review authors should always utilise and demonstrate within their report the underpinning investigative methodology that they are using, e.g. a Fishbone analysis of contributory factors.
2.21
Addressed to: Solent NHS Trust
No Response Published
Link to recommendation 2.21
Recommendation · source text
Serious Incident Review reports must fully comply with guidelines outlined in the National Patient Safety Agency’s RCA Investigation Evaluation Checklist.
2.22
Addressed to: NHS England
No Response Published
Link to recommendation 2.22
Recommendation · source text
A further recommendation was made that NHS England should consider providing a copy of the report to Southern Health NHS Foundation Trust.