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As well as finding artistic inspiration from the weathering of buildings, Howard loves to depict the impact of weather on landscapes that are largely devoid of buildings. Paintings such as ‘A Break in the Cloud’ and ‘Still Some Snow on the Tops’ are illustrative of this obsession. Casting his eye over these paintings, he said, ‘I think my landscape paintings which take contours and weather as their subject are slowly becoming more abstract in appearance.’ Despite these pressures on care providers, their regulatory responsibility to comply with fundamental standards ensuring the safety and wellbeing of service users, as well as their health and safety obligations towards their staff, have not changed.

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. 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 proud to have been part of the historic effort to provide quality Mental Health inpatient care and collaboration with patients during this pandemic. We can be legitimately encouraged and enthused by the roll-out of a COVID‑19 vaccine. While we may feel optimistic that a conclusion to this pandemic is on the horizon, we are not there yet. 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. https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19In this case report, a patient with recurrent laryngeal cancer and a difficult airway had to undergo emergency tracheotomy because of a failed awake flexible fibreoptic intubation. This patient was treated three years earlier with radiotherapy. Awake fibreoptic intubation is the gold standard for many patients with a difficult airway; however, it has its limitations. Reasons for failure of fibreoptic intubation are many among them loss of vision due to bleeding or mucous, tumour size, or severe upper airway narrowing that makes insertion of the cord of the bronchoscope impossible [ 1– 5].

So far, so good, but the world of commercial illustration was beginning to undergo a profound revolution that would see drawings produced by skilled graphic artists replaced by increasingly sophisticated computer-generated images. Howard realised that now was the time to put to good use the techniques of landscape painting that he had learned from ‘Tub’ Williams and turn his attention to the kind of creative painting and drawing that he had been producing for some time either for his own enjoyment or for some private commissions. For airway rescue in this patient, we could not follow the existing difficult airway guidelines, a supraglottic airway device would not have solved the ventilation problem. The MDB Series 58 V 200 A Waterproof MIDI® Fuse Power Distribution Box is an internally bussed fuse holder designed for the high current loads and harsh conditions typically seen in applications such as construction vehicles and agricultural equipment. Effectively acting as a power distribution module, the rugged fuse box is available in configurations for holding two or three MIDI® or BF1 fuses (sold separately) to meet your application requirements.There are no studies that provide guidelines for decision making on performance of a tracheotomy under local anaesthesia, only anecdotic case reports. Some patients present to the emergency room or theatre without warning signs other than dyspnoea or difficulty breathing. Not all patients have an inspiratory stridor. Our patient had none of these symptoms. 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.

The problem is that the three-way win probabilities depend not just on the average abilities of the horses, but also on how reliable they are. A horse that's very unreliable (sometimes runs really fast and sometimes runs really slow) will generally do better in a 3-way race than in a 2-way race, because if they run really fast against one of their opponents they'll run really fast against both of them! Notice that my three horses all finish the course in the same amount of time on average, but horse A still wins out by being unreliable. 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. 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.Videolaryngoscopy may be of help to give an indication of the severity of the airway problems if mouth opening is sufficient which is not the case in our patient was. A videolaryngoscopic-assisted fibreoptic intubation would probably have warned us for the impeding airway disaster [ 13]. Infection control – guidance from Public Health England on required infection controls has evolved frequently as the outbreak has progressed