County Durham and Darlington

Noted (AI summary) International Scientific Supplies Ltd states its urine specimen containers are manufactured and labelled according to UK regulatory requirements, including expiry dates on outer packaging, and that the product complied with obligations at the time of supply. They assert controls were in place and labeling was compliant.

Noted (AI summary) Durham Constabulary's Deputy Chief Constable states that a full review of the case and police actions was undertaken, with the outcome and actions attached to the response. The Police and Crime Commissioner expressed condolences and noted that a review by Durham Constabulary didn't highlight significant failings but resulted in two points of organisational learning and recommendations. The commissioner will monitor the 'Right Care Right Person' model. The College of Policing has contacted Durham Constabulary, who have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. Durham Constabulary will implement recommendations aligned with the National Toolkit for Right Care, Right Person (RCRP), aiming for full implementation by mid-July 2025. These include a review of police systems for further intelligence, supervisor review, and immediate escalation to the Supervisor on a second call about the same person within a 12 hour period.

Noted (AI summary) The DHSC acknowledges concerns about guidance on self-neglect and hoarding disorder, pointing to existing NICE guidance and recent court judgements. They will continue to disseminate such guidance and caselaw through its partners and networks.

Noted (AI summary) NHS England acknowledges the concerns and will review UKHSA's response, while highlighting existing IPC guidance aligning with 'The Green Book' and planned discussions by the Regulation 28 Working Group. The UKHSA expresses condolences and explains its role in iGAS notification and investigation. It states that it has no plans to amend the 'Green Book' guidance regarding alcohol wipes prior to vaccinations, as the matter falls outside of its remit. Browney House Surgery will use the case as a learning exercise, staff will attend Infection Prevention and Control courses, enroll into an Injection Administration Training course and follow local and national guidance. DHSC has determined that UKHSA is better positioned to address the issues raised in the report, as responsibility for guidance on immunization procedures lies with them.

Noted (AI summary) BNF plans to review wording on sedation risks in drug interaction information, to highlight risks of concurrent use of sedating drugs. They have also added pharmacodynamic interaction tables to online versions of the BNF and BNFC. The MHRA will conduct a further assessment of the information provided within the clozapine product information regarding drug-drug interactions, including information for healthcare professionals, patients, families, and carers, as part of a wider review of clozapine to be completed this year. They will engage with relevant stakeholders and monitor the safety of clozapine. The DHSC acknowledges the concerns and notes that the MHRA will conduct a further assessment of the information provided within the clozapine product information. They have shared the report with NICE for consideration.

Noted (AI summary) The IOPC expresses condolences and explains its role in the police complaints system. It details the recommendations made to Durham Constabulary, their response, and the IOPC's follow-up actions to seek further clarity on the acceptance of recommendations. DWP expresses condolences and states that existing guidance and support are adequate for vulnerable customers. They describe the call-back procedure followed and note that the ESA agent did not stop Ms Holmes’ benefit pending receipt of a PW1 form, indicating recognition of her vulnerabilities. TEWV acknowledges concerns and details actions taken including confirming assessment methods, developing an interim policy to address disputes between police and mental health services, and preparing a patient safety briefing on actions to take when disputes arise with partner agencies. The Police and Crime Commissioner acknowledges receipt of the report and expresses condolences. They state they have discussed the concerns with the Chief Constable, who has implemented an interim escalation policy with TEWV pending the roll-out of the national ‘Right Care Right Person’ approach. The constabulary has worked with TEWV to develop a strong partnership plan, implemented an interim escalation policy, and will train frontline officers with a national training package and local guidance.