Dorset

Noted (AI summary) SWASFT has reminded all Private Ambulance Providers (PAPs) of the Appropriate Care Pathway Policy regarding GP referrals and the Dorset Integrated Urgent Care Service (IUCS) GP Alert service. The ECS has been successfully reintroduced and they are reviewing and updating their Business Continuity Plans, looking at adopting the Scribe ECS as a secondary fall-back system. Dorset Integrated Care Board acknowledges the concerns but states Dorset has a well-established Access Mental Health service. They state SWASFT are in discussions with Dorset HealthCare and the police about operational processes and developing the trusted assessor model. The Department acknowledges the concerns raised and outlines the regulatory framework for health and care professionals. It details the SCoPEd framework being adopted by professional counselling bodies but notes these bodies do not fall under Government oversight.

Noted (AI summary) Dorset and Wiltshire Fire and Rescue Service states its commitment to the Joint Emergency Services Interoperability Principles (JESIP) and highlights that the challenges of intra-operability with partners is an area of focus for the Blue Light Group on 18 September 2023. Dorset Police has updated the Niche system by adding a drop-down list regarding Google Translate translation software. They are also implementing changes to Section 2 of Occurrence Logs on Niche, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question. HM Coastguard updated its Capability Matrix to provide partner emergency services across the UK with information on its communications capabilities and uploaded it to the MCA's ResilienceDirect page. 'Connect' call capabilities also now feature in routine exercising with other stakeholders and during the Emergency Control Room visits. The National Fire Chiefs Council (NFCC) supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP) doctrine and will commence work in autumn 2023 to establish a process of providing additional national assurance about the application of JESIP across blue light services. The Trust outlines its existing communication protocols with other emergency services, including ambulance dispatchers' ability to communicate with air ambulances and telephone links with SAR aircraft via the Maritime and Coastguard Agency. It says its staff endeavour to use clear language in all communications, adhering to JESIP principles. NHS England acknowledges concerns but notes many fall outside its remit. It encourages local systems to consider accessibility of resources and highlights agreed actions between Dorset Healthcare Criminal Justice Liaison and Diversion Team and Dorset Police to improve working practices. AACE will work with partners in police, fire and rescue, and search and rescue and the matter of concern will be discussed at the UKSAR Communications working group. The Medical Advisor to NARU is aware of the concerns and is looking to ensure learning from this tragic incident takes place. NPAS and HMCG have agreed to a series of joint familiarisation briefings for all staff and will develop a joint "quick action card" prioritising the need for the Host Force to set an Emergency Services channel on Airwave. Monthly Comms meetings and quarterly meetings will be held and reciprocal visits between the HMCG / NPAS Ops Centres will be arranged. NicheRMS circulated the facts of the coroner's report to Niche Technology customers and is seeking views on changes needed to reduce the chance of a similar occurrence. A temporary solution is proposed, pending consultation with all Niche forces, that will involve staff making the appropriate detention log entry as occurs for other risk assessment questions. The RNLI is updating its page on the government's "ResilienceDirect" platform with details about its capabilities and pulling together material to be shared directly with emergency services partners. The RNLI will also work with the Coastguard to participate in partner awareness 'open day' events. The College of Policing will amend the Detention and Custody APP checklist to include a question about previous arrests. Once this amendment has been made the College will write to forces informing them of the change.

Noted (AI summary) The International Academies of Emergency Dispatch acknowledges the delayed EMS response and identifies contributing factors, including high call volume and Careline's limited information. They suggest that a serious hemorrhage code is equivalent to the initial CAT 3 assignment and that EMDs should stay on the line while providing Dispatch Life Support instructions. Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council are reviewing the cross-agency SCARF process, including information sharing and confidentiality, through a project group. A meeting has already taken place to discuss this. Kingston upon Hull City Council is planning several measures: relocating taxi ranks, designing a signalized crossing, relocating a crossing facility, considering footpath widening, and implementing a 20mph zone. These are in various stages of feasibility, design, and consultation, with timelines specified.

Noted (AI summary) National Highways will conduct a study to identify options for improving road user notification of incidents, aiming to complete it by late Summer/Autumn 2023 and prepare an implementation plan. Dorset Road Safe partnership will add a clear link to their website indicating who to contact regarding road obstructions, highlight associated dangers, and launch a communications campaign across various media platforms to alert road users to obstructions on Dorset roads. Dorset Council, as part of Dorset Road Safe, will introduce a simple reporting process and contact information for obstructions/debris on the road to their website. A communications campaign will be constructed to alert all road users around obstructions/debris on Dorset’s roads using various media platforms. The Department for Transport outlines existing legislation and guidance regarding road obstructions, including the Highways Act 1980 and the Highway Code. They conclude that no further action is appropriate for the Department to take at this stage. BCP Council states that the response letter from the Dorset Police Chief Constable conveys the views of BCP Council, via the Dorset Road Safe Partnership.

Noted (AI summary) NHS England developed a training programme for Adult Safeguarding in Secure and Detained Settings in conjunction with HMPPS and HEE. The response also mentions a Ministry of Justice NPS toolkit. HMPPS will review and develop the key work model to improve safety and reduce reoffending, including making it more flexible. HMP Guys Marsh introduced an assurance check for weekly case notes and a weekly multi-disciplinary meeting to discuss and share information regarding drug ingress, issuing Governor's Notices and harm minimisation guidance as needed. The response refers to the Director General's letter which outlines the actions being taken at HMP Guys Marsh, such as introducing a Buddy scheme, writing local guidance, introducing an assurance check, and a weekly multi-disciplinary meeting.

Noted (AI summary) The ICB notes that patient information is accessible via the Dorset Care Record (DCR) and that this gentleman has had a DCR since February 2018, which has been accessed by health and social care staff. They have shared the findings with the relevant teams to inform any future improvements to the DCR. Dorset Council confirms that they ensure health is consulted on medication, its use, storage and any risks at assessment and review points. They also confirm written confirmation from Health in writing of any known risks linked to the use of specific medications for named individuals and how to safely manage these is obtained. The learning recommended from the action plan was shared with relevant managers in February 2023.

Noted (AI summary) NHS England will request assurance from regional Directors of Commissioning that actions regarding the use of the PSA (proactive systematic assessment) vital signs tool have been implemented and evidenced by April 2023. They will also work with HMPPS on their review of PSO 1600: Use of Force, providing clinical leadership on section 6. A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions and healthcare staff are to be trained alongside prison officers. HMPPS implemented a memorandum of understanding with the new healthcare provider at HMP Portland regarding the role of healthcare during use of force incidents. Whitewood furniture beds have replaced metal bedframes at HMP Portland. The Governor of HMP Portland confirms their involvement in the HMPPS response to the Regulation 28 report.

Noted (AI summary) NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare Trust to amend the Pan-Dorset Standard Operating Procedure and discussing with AMHPs how to succinctly share information with GPs. The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022. Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The AMHP service managers will ensure review of records before assessment and there is a new mandatory field to notify the allocated social care practitioner of any Mental Health Act assessment. The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on informal patient status, ensuring comprehensive discharge summaries are sent to GPs after Mental Health Act assessments. Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff to use Niche for logging decisions, and are including a session on log keeping in Vulnerability 4 training; revised processes are in place to monitor training activity. The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical conditions make specific training impractical for non-medical personnel. The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments. The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting out further details. The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services in neuroscience centers in ICSs. The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric admissions. They will also discuss these issues with the President of the Royal College of Psychiatrists.

Noted (AI summary) The ECB intends to circulate communications to appropriate representatives, including a list of steps from the CAA, within one month and emphasize the need to share the information directly with players. All corporate travel for ECB employees and representatives must be booked through the ECB's travel management company Ventur. The RFU cascaded the findings in the Regulation 28 Report to all clubs involved in the Premiership. The RFU also raised this subject at the June meeting of the Professional Game Board. The EFL reissued guidance to all Clubs, which was received in March 2021. The EFL will reissue a link to the guidance in advance of each transfer window. The British Horseracing Authority briefed its Board and prepared a draft guidance note to send to its member bodies and engaged with the Civil Aviation Authority (CAA). The FA states they were not aware of the coroner's report until it was provided by the English Football League. The FA relayed CAA guidance on illegal flights to clubs and Registered Intermediaries in March 2021. The Department for Transport and the CAA are reviewing the powers available to them in investigating breaches of aviation regulations and what powers they would find of assistance in their investigative and enforcement role. The Jockey Club requires aircraft operating at its racecourses to obtain prior permission, demonstrate pilot licensing, provide aircraft registration and insurance, and confirm whether flights are private or commercial. The Jockey Club and Helicopter & Aviation Services Ltd provide records of aircraft activities to authorities when requested. The organisation circulated a note to its members recommending that they do not pay for or use unlicensed commercial flights, sharing the concerns of the Dorset Coroner. The Professional Footballers Association has written to its current members and put information on its website to raise awareness on the issue of unlicensed aircraft, and attached the guidance issued by the CAA. UK Athletics has distributed information regarding private flights to World Class Programme athletes, coaches, support staff, and known agents, emphasizing the need to check the legality of flights. The LTA sent a communication to relevant players on 9 August 2022 regarding commercial flights from unlicensed operators, including a link to CAA guidance. The Institute of Directors included a statement in its 'Influence' email to 20,000 members and posted a notice on its website warning of the dangers of unauthorised flights, following a request from the Civil Aviation Authority. The Premier League will send correspondence to the Legal, Club Secretarial, and Football departments at each of the Clubs. The Premier League met with Clubs at the Annual General Meeting on 9 June 2022 and raised the issue to the Chairs/Chief Executives/Owners attending. The Confederation of British Industry plans to publish an article on employee wellbeing and safety linking to the Sala case, use social media to amplify the importance of employee well-being and safety, and flag the case to its account managers who manage the CBI's aerospace members. The Rugby Football League wrote to all member clubs advising them of the situation regarding private flights and asking them to ensure they do not use such flights. The Department for Digital, Culture, Media and Sport shared CAA guidance with sports organisations, Live music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians' Union. The RFU requested Premiership clubs review the PFD report on commercial flight chartering and ensure flights are legal and have required authorisations, certifications and permissions, and pass the information to relevant employees. The British Chambers of Commerce circulated briefing materials to its Chamber of Commerce members, raised the issue in a call with Chamber of Commerce CEOs, and highlighted the importance of taking action at the BCC Board. Motorsport UK will publish advice to its license holders on its website and in its monthly ezine regarding air-worthiness of chartered aircraft and pilot qualifications. The Executive Association of Great Britain stated that the report and concerns are not applicable to their particular circumstances as they do not arrange travel for members, and members do not travel by air to attend meetings. UK Sport asserts that the use of illegal private plane journeys is not permitted with their funding and that the risk of government funded sports using them is minimal. The EFL circulated a CAA notice to club secretaries raising awareness of the risks of illegal public transport using unlicensed aircraft.

Noted (AI summary) NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.

Noted (AI summary) The Department for BEIS acknowledges the report but asserts that existing product safety regulations are adequate for mobility scooters. They argue that placing an obligation on individuals to undertake an assessment before purchasing specific products would be disproportionate and propose that no further action is taken.