Cornwall and the Isles of Scilly

Action Planned (AI summary) Royal Cornwall Hospitals NHS Trust has improved stroke care by ringfencing stroke beds, increasing consultant availability in ED and Phoenix Ward, and reviewing data, leading to significant improvements in timely stroke unit admissions. A cross-organisational working group will also form to develop a business case for capacity and workforce planning. • The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. • This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow. • A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case.

Action Planned (AI summary) Royal Cornwall Hospital is changing their language in the Emergency Department when asking parents about how babies are fed from ‘bottle’ to ‘formula’ and this will be reflected in ED documentation. Maternity services use routine enquiry about the exact nature of bottle feeding as a mandatory question at every safe opportunity and have an Enhanced Continuity Pathway developed and implemented along with pregnancy circles with face-to-face translators. Cornwall Council has secured funding to rewrite/update the ‘Essential Guide to feeding and caring for your baby’, deliver a mandatory webinar on language/terminology and safe formula guidance by the end of January 2026, finalise and publish Interpretation SOP and add targeted checks on recording "what’s in the bottle". Cornwall Partnership NHS Foundation Trust has instructed Minor Injuries Unit staff to ask for specific details if there are any concerns about a child’s nutrition including what is being fed. Staff have also been reminded that children attending the MIU should be weighed on each visit, and for those aged 2 and under, this should also be recorded in the child’s red book.

Action Planned (AI summary) A multidisciplinary group has been established to advise on strengthening governance for prescribing medications following unexpected hospital admission after day case surgery, with implementation planned by May 2026. Four workstreams have been identified, and an audit is planned for September 2026.

Action Planned (AI summary) The landlord will fit a grab rail on top of a wall to improve handrail safety and expects lighting work to be completed in 3 weeks. Signs advising of steep steps were installed soon after the property purchase, and a non-slip coating was applied to the steps.

Action Planned (AI summary) Cornwall Council's Adult Social Care has included thematic reviews of Mental Health Act assessments into their audit program, and has developed and disseminated guidance for Approved Mental Health Professionals (AMHPs) on safety planning following assessments. The guidance has been shared with AMHPs and is progressing through governance processes before formal adoption.

Action Planned (AI summary) Sanctuary Housing commits to an internal review following the Coroner's findings to identify improvements that can be made to its multi-agency approach to ASB and cuckooing, and will externally benchmark its policies and procedures against others in the social housing sector. They are considering training and additional guidance to complement existing policy and procedure around safeguarding and cuckooing, and developing specific guidance for front-line housing staff.

Action Planned (AI summary) The MHCLG response focuses on the government's broader efforts to increase social housing supply, tackle homelessness, and address rogue practices like cuckooing, including a new offence in the Crime and Policing Bill. They also mention publishing good practice case studies to support landlords dealing with antisocial behaviour and efforts to improve mental health care, but does not describe specific actions directly responsive to the case.

Action Planned (AI summary) University Hospitals Plymouth NHS Trust will undertake regular audits of nutrition care, provide education on measuring mid-upper arm circumference, and share findings from an investigation across the organization.

Action Planned (AI summary) The DHSC acknowledges concerns about ambulance response times, A&E overcrowding, and delayed social care packages. They mention the upcoming 10-Year Health Plan focusing on shifts in care delivery and investments in integrated health and social care services through the Better Care Fund.

Action Planned (AI summary) NHS England will discuss details of the case with the NHS England AMPDS clinical coding sub-group, in collaboration with PDC, to determine if there are opportunities to improve the assessment and differentiation of abdominal pain presentations within the AMPDS triage system. NHS England has additionally shared the Coroner’s concerns with PDC.

Action Planned (AI summary) The DHSC acknowledges concerns around ambulance response times, A&E overcrowding and delayed social care packages. The government plans to publish a 10-Year Health Plan and will set out lessons learned from winter pressures on urgent and emergency care services and improvements for 2025/26.

Action Planned (AI summary) The government acknowledges concerns around emergency service pressures and is working with NHS England to address them, with a focus on ambulance response times and handover delays; the upcoming 10-Year Health Plan will set out radical reforms for the NHS and address these issues.

Action Planned (AI summary) Police officers are being trained to dial 999 from the scene for medical support, and SWAST has implemented a new communication pathway to improve inter-agency information sharing. SWAST is implementing a Timely Handover Process at RCHT to instigate rapid handover if not undertaken within 90 minutes of arrival. Devon & Cornwall Police is participating in a multi-agency group to promote closer working arrangements between emergency services, with meetings scheduled to identify and address specific areas for improvement. The Assistant Chief Constable has reiterated the expectation that sergeants can redeploy police resources in liaison with an inspector and/or the Force Incident Manager.

Action Planned (AI summary) National Highways has agreed, but not yet secured, business case and funding for the Average Speed Camera System (ASCS) and work is scheduled to commence in Q1 2025/26. They plan to complete the initial design completion package for ASCS and speed limits by March/April 2025.

Action Planned (AI summary) The DHSC acknowledges concerns about pressures on the South West Ambulance Service and highlights the ICB's winter plan. They also mention a forthcoming 10-Year Health Plan and an independent commission into adult social care.