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A trust-wide safety review prompted by the death of a 25-year-old woman is facing a delay of up to nine months – something which has greatly concerned a coroner and led him to warn of the risk of future deaths.

As reported by HSJ yesterday, area coroner James Bennett is calling on Birmingham and Solihull Mental Health Foundation Trust to speed up an audit process (by its clinical governance committee) which is being blamed for a lengthy delay in patients’ cases being reviewed.

Internal investigations into the death of Natasha Adams, completed in December 2021, said the trust should audit other cases to check compliance with a care policy.

The young mother’s level of care was downgraded under the policy shortly before her death in a move her family suggested had a “dramatic impact”.

In a note to the trust’s CEO the coroner warned “no action had been taken” four months after the internal investigation and said there were fears “staff holidays” could delay approval of the audit until September.

The trust told HSJ it was committed to completing the audit by the end of June and put delays in completing it down to capacity constraints caused by omicron-wave staff sickness.

ICS frank on handover failings

As concerns in many parts of the country grow over the dangers posed by ambulance handover delays, one health system has been candid about its own plan for dealing with the problem falling short.

Lincolnshire integrated care system’s leaders have admitted in a document to NHS England that they do not have a ‘robust’ response to managing the risks posed by ambulance handover delays and poor response times.

The document, which is from early April and was published by the Lincolnshire Partnership Trust last week, sets out how it would bring down handover delays with the eventual goal of eliminating waits of more than one hour by November 2022. Areas for further work set out in the report include changing public behaviour, and signposting and re-direction away from accident and emergency.

The system’s acute provider, United Lincolnshire Hospitals Trust, was consistently among the trusts accounting for the highest proportion of ambulance delays over winter.

An ICS spokesperson said “significant progress” had been made since the document was published, including establishing key trigger points and corresponding actions for partners to take. They said the request for support from NHSE was part of routine conversations rather than a formal process. 

Also on today

In The Integrator, Dave West anticipates what could be in Claire Fuller’s “stocktake” review of primary care and says its ideas need to be radical, and in a comment piece, Pritesh Mistry says Sajid Javid’s promised digital health and care plan will need to integrate the several digital commitments made in recent years and identify past failures.