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During the intubation procedure, we could not pass the fibrosis with the insertion cord of the flexible scope nor tracheal tube, which is an unusual situation. This problem, however, caused acute laryngospasm and airway obstruction that mandated emergency coniotomy. Along with their obligations to service users, providers must also discharge their responsibilities to staff under the Health & Safety At Work legislation. The issue of PPE is prominent again here, if members of staff feel that they have not been provided with all the equipment they needed to keep them safe. Inevitably, situations could arise where there is a tension between a provider’s obligations towards their service users and towards their staff.

NAPICU is also pleased to report the outcomes of a collaboration to systematically evaluate the performance of PPE used during physical intervention. A brief summary of this project is included in Appendix 2. The full manuscript and data are currently submitted for peer review and publication. In the interim, the learning from the evaluation has been used to inform developments in this Guidance which may be of assistance to Inpatient Services considering this difficult area. For example, providers must still comply with regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that relates to the provision of safe care and treatment, including infection control. In a letter to care providers(2) in March, CQC wrote: ‘We encourage you to use your discretion and act in the best way you see fit.’ This could be taken as indicating there will be some leeway in how the regulator assesses compliance during these exceptional circumstances – but the question becomes, how much? When inspection activity resumes, there is the possibility that CQC may make criticisms in inspection reports or pursue enforcement action if they consider that, despite all the pressures they were facing, a provider did not do enough to comply with the applicable guidance. However, it is unclear quite what lies ahead. While some deviation from ‘usual’ standards may be tolerated, where will the bar be set? Further guidance from CQC on this would certainly be welcome. Awake fibreoptic intubation is accepted as the gold standard for intubation of patients with an anticipated difficult airway. Radiation fibrosis may cause difficulties during the intubation procedure. We present an unusual severe case of radiation induced changes to the larynx, with limited clinical symptoms, that caused failure of the fibreoptic intubation technique. A review of the known literature on radiation fibrosis and airway management is presented. 1. Introduction

Matthew Kennedy

Practice issues and guidance on delivering and managing occupational therapy and activity-based intervention in PICUs in the context of Covid-19 Much has been learned since the first publication of the NAPICU Managing Acute Disturbance in the Context of COVID‑19 Guidance in March 2020. The last nine months have seen astonishing progress in the understanding of COVID‑19 and the ways in which successful Mental Health Inpatient Services can be maintained. For those of us who have been both delivering and receiving services during this period, the journey continues together towards shared interests and understanding. The UK became the first country in the world to authorise the use of a COVID‑19 vaccine which is being rolled out across the nation. This will surely reach Mental Health staff and patients sometime soon. That said, there is a long Winter ahead and Services must remain focused, diligent and determined to maintain the approach that has shown success for mental health care while managing potential for infection. High-frequency jet ventilation is dangerous in patients with severely obstructed airways because of the risk of barotrauma. In some patients with laryngeal tumours, a tracheotomy can be prevented by (laser) debulking when the tumorous lesions are soft. However, the trachea needs to be intubated most of the times during these procedures. https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians

begin{pmatrix}P_{ABC} \\ P_{ACB} \\ P_{BAC} \\ P_{BCA} \\ P_{CAB} \\ P_{CBA}\end{pmatrix} = \begin{pmatrix}P_{AB} \\ P_{BA} \\ P_{AC} \\ P_{CA} \\ P_{BC} \\ P_{CB}\end{pmatrix}The Covid-19 pandemic has stretched all parts of the health and social care system to the limit as they have battled with the challenges posed. Within this, care homes have been described by some as an ‘epicentre’ of the disease in the UK. Public, and political, support and respect for the social care sector has never been higher as it has pulled out every available stop to provide the best possible care for service users. However, despite the recognition of the unprecedented challenges, and Care Quality Commission (CQC)’s introduction of the Emergency Support Framework, care providers need to be mindful that the legal frameworks – and the possibility of regulatory scrutiny for failing to meet them – remain in place.

Similarly, in a letter written more recently(3)(in May) to ADASS, Mr Justice Hayden, vice president of the Court of Protection, issued a reminder around continuing obligations under the Mental Capacity Act. A concerning emerging issue during the crisis has been relatives seeking to take their loved ones out of homes due to infection concerns, raising mental capacity and best interest issues. In addition, providers need to consider(4) whether changes to a person’s care or treatment arrangements as a response to the outbreak constitute a new deprivation of liberty. Justice Hayden wrote that any belief that deprivation of liberty processes could be deviated from because of the crisis was ‘entirely misconceived’. He noted that there had been a ‘troubling drop’ in Mental Capacity Act 2005 s.21A applications. The NRP construction consultancy arm is the origin of our organisation. Operating since 1947 the company has thrived through generations of changes to building standards, practices and methodologies. Capturing and learning as the industry changes, we have delivered almost every type of construction project across all sectors. Infection control – guidance from Public Health England on required infection controls has evolved frequently as the outbreak has progressed As a business that designs and delivers projects, from office buildings and homes to entire public realms and streetscapes, we understand that reflecting the needs of the communities we serve is key to long-term success – not just for our clients but for those that use and interact with these spaces. We provide a Director led approach for all clients, with commercial expertise to deliver the best results for each and every project. We pride ourselves in having an efficient and proactive approach and a network of partners capable of resourcing all design, technical and legal requirements.Our in-depth knowledge of the areas in which we work in, allows us to provide considered advice on development and investment strategies, risk management, procurement strategy and design development. title = {Measurement of the dijet transverse thrust distribution in proton - anti-proton collisions}, So there can't possibly be any way of calculating the 3-way probability, given only knowledge of the head-to-head probabilities.