Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 31
Oldham Borough Council Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
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Oldham Council ASC Train duty workers to cover the Learning Disabilities and Autism hospital-discharge tracking role when the named worker is unavailable.
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Oldham Council ASC Add learning and guidance documents to the Adult Social Care SharePoint site for ongoing practitioner use.
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Oldham Council ASC Add the learning to mental-capacity-act theory-to-practice training.
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Oldham Council ASC Assign responsibility for hospital-discharge work to a named worker within the Learning Disabilities and Autism Team.
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Oldham Council ASC Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
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Oldham Council ASC Establish proactive hospital-admission tracking and multiagency engagement by the named Learning Disabilities and Autism hospital-discharge worker.
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Oldham Council ASC Create and disseminate a seven-minute briefing across Adult Social Care on learning from the case.
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Oldham Council ASC Review how acute hospital admissions and discharges are managed by Adult Social Care mental-health teams.
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Oldham Council ASC Ensure Adult Social Care mental-health teams track supported individuals’ admissions and engage fully in hospital admission and discharge planning.
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Northern Care Alliance NHS Foundation Trust Implement Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
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Northern Care Alliance NHS Foundation Trust Complete Oliver McGowan Part 1 learning disability and autism training for Trust staff under the mandated programme.
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Northern Care Alliance NHS Foundation Trust Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
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Northern Care Alliance NHS Foundation Trust Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
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Northern Care Alliance NHS Foundation Trust Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
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Northern Care Alliance NHS Foundation Trust Develop Oliver McGowan trainer capability for Tiers 1 and 2 training.
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Northern Care Alliance NHS Foundation Trust Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
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Northern Care Alliance NHS Foundation Trust Use and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
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Northern Care Alliance NHS Foundation Trust Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
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Northern Care Alliance NHS Foundation Trust Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
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Northern Care Alliance NHS Foundation Trust Audit monthly compliance with arrival checks for contact details and cross-referencing ambulance arrivals with patient report forms.
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Northern Care Alliance NHS Foundation Trust Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
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Northern Care Alliance NHS Foundation Trust Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
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Northern Care Alliance NHS Foundation Trust Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
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NHS Greater Manchester Integrated Care Board Share learning from this PFD with Greater Manchester acute hospitals and the wider health and care system through Assistant Directors of Quality networks.
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NHS Greater Manchester Integrated Care Board Monitor Oliver McGowan mandatory training compliance and completion rates at Directorate and Trust levels.
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NHS Greater Manchester Integrated Care Board Share learning from the locality practice review across Greater Manchester.
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NHS Greater Manchester Integrated Care Board Remind staff to check for and seek Hospital Passports at every presentation, regardless of whether records or systems identify one.
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NHS Greater Manchester Integrated Care Board Conduct a locality practice review with stakeholders to improve care for patients with learning disabilities and complex needs in Oldham.
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NHS Greater Manchester Integrated Care Board Remind staff about safeguarding vulnerable patients and referral responsibilities and mechanisms through a Take 5 Briefing.
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NHS Greater Manchester Integrated Care Board Remind staff of their responsibilities towards patients with learning disabilities and complex needs through a Take 5 Briefing.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to utilise hospital passports
Wider context from the report “1. The hospital passport was not utilised .
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information about care needs in referrals to specialist services
Wider context from the report “1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
Wider context from the report “1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the commissioned IMCA service to ensure information is shared with decision-makers when interested persons are not invited to medical best-interest meetings.
Verbatim wording from the response “The Council can also confirm that the commissioned IMCA service is able to cover medical best interest decisions. adult social care will work with them to ensure that where they feel interested persons have not been invited to medical best interest decision meetings, they ensure appropriate information is shared with the organisation leading the decision.” Source location Response from Oldham Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train duty workers to cover the Learning Disabilities and Autism hospital-discharge tracking role when the named worker is unavailable.
Verbatim wording from the response “Learning Disabilities and Autism Team to train duty workers to cover this role when the named worker is not available.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add learning and guidance documents to the Adult Social Care SharePoint site for ongoing practitioner use.
Verbatim wording from the response “Documents to be added to ASC SharePoint site as ongoing practitioner learning and guidance.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the learning to mental-capacity-act theory-to-practice training.
Verbatim wording from the response “Learning to be added to MCA theory to practice training.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign responsibility for hospital-discharge work to a named worker within the Learning Disabilities and Autism Team.
Verbatim wording from the response “Key Actions:
Learning Disabilities and Autism Team to assign responsibility for hospital discharge work to a named worker within the service.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and disseminate a risk-rating framework for safe attendance decisions at other organisations’ medical best-interests meetings, including information-sharing considerations.
Verbatim wording from the response “Risk rating framework to support practitioners to make safe and informed decisions regarding attendance at medical best interest’s meetings led by other organisations to be created and disseminated across ASC.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish proactive hospital-admission tracking and multiagency engagement by the named Learning Disabilities and Autism hospital-discharge worker.
Verbatim wording from the response “Named Learning Disabilities and Autism hospital discharge worker to proactively track people open to the team who are admitted to acute hospital and fully engage in multiagency working.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and disseminate a seven-minute briefing across Adult Social Care on learning from the case.
Verbatim wording from the response “7 Minute briefing to be created and disseminated across ASC re: Learning from the case of MF.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review how acute hospital admissions and discharges are managed by Adult Social Care mental-health teams.
Verbatim wording from the response “ASC Mental Health teams to review how acute hospital admissions and discharges are managed by their area of service.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure Adult Social Care mental-health teams track supported individuals’ admissions and engage fully in hospital admission and discharge planning.
Verbatim wording from the response “ASC Mental Health Teams to ensure individuals open to their teams are appropriately tracked and full engagement in multi-agency working is in place from ASC re the hospital admission and discharge planning.” Source location Response from Oldham Council - Action Plan
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
Verbatim wording from the response “Patient Care Alert (“PCA”)” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete Oliver McGowan Part 1 learning disability and autism training for Trust staff under the mandated programme.
Verbatim wording from the response “Oliver McGowan training” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Verbatim wording from the response “MCA audits” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Verbatim wording from the response “MCA training” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
Verbatim wording from the response “Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) policy” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop Oliver McGowan trainer capability for Tiers 1 and 2 training.
Verbatim wording from the response “Oliver McGowan training” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
Verbatim wording from the response “3. A prompt will now appear on the ‘patient status at a glance’ board (the bed board) when a Hospital Passport is available and in use. This will reiterate the policy provision with regard to the visibility and prominence of Hospital Passports. The board features a learning disability symbol and staff can include written confirmation of “Hospital Passport in place”.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
Verbatim wording from the response “The Enhanced Patient Observation (“EPO”) policy review and audit tool” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
Verbatim wording from the response “Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) policy” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
Verbatim wording from the response “Share Learning Take 5” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit monthly compliance with arrival checks for contact details and cross-referencing ambulance arrivals with patient report forms.
Verbatim wording from the response “1. Hospital systems containing next of kin contact details must be checked for accuracy and updated on a patient’s arrival to the hospital. The Emergency Department Lead Nurse will raise this at an Emergency Department reception team meeting so that patient contact details are confirmed and if a patient has arrived by ambulance, cross referenced with the PRF (patient report form) on arrival.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Verbatim wording from the response “The Trust Level 3 safeguarding adult mandatory training programme has a significant focus on the MCA and its application in practice. Current organisational compliance with Level 3 Safeguarding adult training is at 95%. MCA and Deprivation of Liberty Safeguards (DoLS) training have been better defined to support the application of MCA beyond the requirement for application of a DoLS authorisation to ensure the MCA is more effectively considered for a wider group of patients, including those with learning disabilities. The application of the MCA is essential to the EPO procedures to ensure the least restrictive option of observation and support is provided.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
Verbatim wording from the response “Daily safety huddles
Further to the PCA, any patient with a learning disability/Hospital Passport will automatically be ‘red flagged’ during daily safety huddles for nursing staff. This adds a further layer of awareness of this cohort of patients and their specific needs. The senior nurse (ward manager) will have oversight of vulnerable patients.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
Verbatim wording from the response “Senior Nurse Walkabout” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from this PFD with Greater Manchester acute hospitals and the wider health and care system through Assistant Directors of Quality networks.
Verbatim wording from the response “Learning from this PFD will be shared specifically with the GM acute hospitals and the wider health and care system through the NHS GM Assistant Directors of Quality networks.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Oliver McGowan mandatory training compliance and completion rates at Directorate and Trust levels.
Verbatim wording from the response “• Compliance with the Oliver McGowan mandatory training and completion rates are being monitored at Directorate and Trust levels.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the locality practice review across Greater Manchester.
Verbatim wording from the response “• A locality practice review process has begun in partnership with key stakeholders to lead forward improvement work in Oldham for patients who have a learning disability and complex needs to improve the care experience for our most vulnerable patients and residents. Learning from the” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to check for and seek Hospital Passports at every presentation, regardless of whether records or systems identify one.
Verbatim wording from the response “• As a health and care system, we recognise the importance of Hospital Passports. Staff have been reminded to immediately aware of and seek out whether a Hospital Passport is held, regardless of whether or not one is noted on the patient records, Trust or community systems or is available at any given presentation to services for care.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a locality practice review with stakeholders to improve care for patients with learning disabilities and complex needs in Oldham.
Verbatim wording from the response “• A locality practice review process has begun in partnership with key stakeholders to lead forward improvement work in Oldham for patients who have a learning disability and complex needs to improve the care experience for our most vulnerable patients and residents. Learning from the” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff about safeguarding vulnerable patients and referral responsibilities and mechanisms through a Take 5 Briefing.
Verbatim wording from the response “• Staff have been reminded via a Take 5 Briefing (attached with this letter) of the importance of Safeguarding vulnerable patients and the responsibilities and mechanisms of making referrals.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff of their responsibilities towards patients with learning disabilities and complex needs through a Take 5 Briefing.
Verbatim wording from the response “• Staff have been reminded via a Take 5 Briefing (attached with this letter) of their responsibilities towards patients with learning disabilities and complex needs.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The initial absence of the Hospital Passport did not impact the patient’s care, although its immediate availability remains important.
Verbatim wording from the response “The Trust’s review determined that Mr Fernandez’s care was not impacted by the initial absence of the Hospital Passport. Notwithstanding this however, the Trust recognises that it’s proper utilisation depends on hospital staff being immediately aware as to the need for this document to accompany a patient with a learning disability or if one is not available to create one.” Source location Response from Northern Care Alliance NHS Foundation Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Separate concerns are assigned to Northern Care Alliance, Oldham Social Services and Oldham Independent Mental Health Advocate for response.
Verbatim wording from the response “An investigation into this matter of concern has been undertaken by ████████, Associate Director Quality & Safety (Oldham) and ████████, Assistant Director Patient Services, both of NHS GM. I understand that separate matters of concern have been directed to Northern Care Alliance, Oldham Social Services and Oldham Independent Mental Health Advocate and that they will be provided their responses.” Source location Response from NHS Greater Manchester Integrated Care Partnership Board
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