Cornwall and the Isles of Scilly

Noted (AI summary) The College of Policing explains its role and details existing guidance and learning material addressing the risks associated with Taser use, particularly multiple activations, and highlights the role of SACMILL in advising on medical issues. The Home Office acknowledges the concerns about Taser use and refers to existing policy, guidance, training, and scrutiny mechanisms. It states satisfaction that current measures are adequate but acknowledges every death in police custody is a tragedy.

Noted (AI summary) Cornwall Council has replaced all Nimbus mattress systems in the community with Elite systems. All Nimbus stock has been destroyed. The council states that the previous service records indicate that there is no evidence to suggest that alarm failure was an issue on the Nimbus system. The MHRA explains CE marking and post-market surveillance processes for medical devices like mattresses, noting that the incident was not reported to them. They state that without a serial number to identify the mattress, a report may be inconclusive and there is no further action that MHRA can take.

Noted (AI summary) Devon Doctors no longer provides out-of-hours services in Cornwall and has passed the report to the new provider. They reviewed the concerns in relation to their Devon services, noting that information sharing is partly outside their control but that clinicians have appropriate pathways to escalate concerns, including Community Mental Health Practitioners in their Clinical Assessment Service. A Rapid Reassessment Pathway for individuals with mental health needs discharged from secondary to primary care has been developed by Livewell Southwest. NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, and to consider giving patients written guidance on what to expect and when following a referral. Cornwall NHS Trust has implemented a new assessment service with designated administrators to manage referrals, and developed new Safety Plans for patients containing crisis information. The Trust is also reviewing the Out of Hours services and any changes will be communicated to external providers.

Noted (AI summary) Cornwall Council has investigated the collision and determined that adding safety measures such as crash barriers is unlikely to improve safety and may cause additional injuries; they will continue to monitor the site.

Noted (AI summary) The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing bed provision in Cornwall. NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. They are also reviewing provision for individuals placed out of county to inform future commissioning.