East London

Noted (AI summary) The DHSC acknowledges the coroner's concerns, notes that the CQC has been informed and that actions have been taken by the Trust, and emphasizes the importance of patient safety and the new Patient Safety Incident Response Framework (PSIRF). Barts Health is reviewing its Bereavement policy to clarify guidance on the removal of tubes, lines, and devices, mandating they remain in place until after discussion with the medical examiner, decision on coronial referral, and issuance of the death certificate. They will also cascade learning from this incident and embed it within training.

Noted (AI summary) The DHSC acknowledges concerns about patient congestion and triaging/care provided to a patient with sickle cell anaemia, noting that the Barts Health NHS Foundation Trust will respond directly with details of actions they are taking. They also mention a government plan to reform the NHS.

Noted (AI summary) The DHSC refers to existing guidance on managing anaphylaxis in schools and the role of the Expert Advisory Group for Allergy, noting that adrenaline auto-injector suppliers were in stock at the time.

Noted (AI summary) NHS England is reviewing its communications approach to alerting GP practices about medicine shortages and the Pharmacy and Medicines Optimisation Team is reviewing the use of AAIs and their supply. All reports received are discussed by the Regulation 28 Working Group. BSACI is developing an online allergy education platform for healthcare professionals and others, covering anaphylaxis recognition and management. The BSACI allergy action plans include difficulty swallowing as a manifestation of anaphylaxis and state "if in doubt, give adrenaline." The RCP will work with other colleges and societies to agree and support standards of care and education related to allergy, including updating standards for allergy accreditation and promoting multidisciplinary care. As a member of the EAGA, the RCP is working on the development of the UK National Allergy Strategy. The GDC will write to NICE to suggest they review anaphylaxis symptoms and guidance for dental professionals, and will consider changes to CPD requirements regarding medical emergencies as part of a review concluding in 2025. The GPhC acknowledges supply issues with adrenaline autoinjectors and highlights existing standards for pharmacy professionals, signposting other resources for safe AAI use and directing medicine supply inquiries to the DHSC. They offer a meeting with Hannah's family. The RCPCH will share information from the report with its members via a patient safety portal and for discussion with the Clinical Quality in Practice Committee, where further actions may be identified.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about the investigation and governance processes at Barts Health NHS Foundation Trust following a patient fall. They mention the PSIRF, which became a contractual obligation for all Trusts from April 1, 2024, and that the CQC will be discussing the PSIRF in upcoming meetings with the Trust.

Noted (AI summary) Sunlight Care Group has updated policies, conducted a Serious Incident Review, and commenced a training program for staff. The training covers topics such as recognizing self-neglect, home safety, nutrition, and risk management, with a detailed schedule outlined in the response. The council has already completed a Safeguarding Adults Review referral and held a meeting with Sunlight Care, implementing a quality improvement plan and enhanced monitoring. They also plan further actions including a learning event with ASC, Sunlight Care and ELFT, a review of safeguarding procedures and training on implementing inquest lessons. The DHSC acknowledges the concerns raised in the report, referencing the Care Act 2014 and Mental Capacity Act. They highlight existing resources like the Care Workforce Pathway without committing to specific new actions. The Trust has increased time slots in the dressing clinic, staffed it with a substantive nurse, and will review with staff the need to proactively arrange professional meetings when they witness concerns. They also describe changes to wound care pathways.

Noted (AI summary) The Trust will not allow removal or deferral of cancer patients on a Patient Tracker List without consultant approval. A restructure of cancer administration pathways is underway and an external review of controlled medication practices is planned. The Trust has changed the process of Controlled Medication Keys and is trialing a digital key system and exploring installing CCTV. The MHRA acknowledges the concerns but states they cannot comment on medical advice or care quality. They explain the MHRA's role in assessing medical devices and note they received a previous NRLS report regarding a gastrostomy balloon device, but the investigation was closed in August 2023 due to the implementation of ENFit standards. The DHSC acknowledges the concerns regarding the care provided by the Trust and its processes. It outlines the roles of NHS England, CQC and MHRA and refers to NICE guidance and NIHR funded studies on sepsis.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns and states that the matters are primarily local issues for Barts Health NHS Foundation Trust to address. Barts Health acknowledges documentation issues and is planning several actions including consultant re-induction, audits, training on capacity assessment and sedation, and recruitment of a learning from deaths lead.

Noted (AI summary) NHS England acknowledges the concerns regarding epilepsy patient reviews and medication management, highlighting existing NICE guidelines, RCGP eLearning resources, and tools for structured reviews. They note workforce capacity challenges and share the report with regional colleagues, also describing the Regulation 28 Working Group. The Royal College of Physicians supports the Association of British Neurologists' position regarding national guidance on epilepsy monitoring, annual follow-up in primary care, and the need for clear communication in discharge letters. They highlight the low number of neurologists and epilepsy specialist nurses in the UK. The RCGP plans to highlight NICE guidelines and educational material on SUDEP through its Clinical Networks and member forums. It will also recommend to NHS England the need for standardised urgent care pathways for epilepsy patients and address issues relating to waiting times for appointments.

Noted (AI summary) Outlook Care has implemented an action plan including external feedback, stakeholder inclusion in reviews, and collaborative working with LBWF. They've revised their Missing Person policy, provided staff training, and conducted spot checks on 1:1 support, issuing guidance on maintaining a 'line of sight'. Future actions include business continuity tests, audits of risk management, and revised induction formats. The CQC reviewed information on Waterside Lodge Recovery Centre and requested a copy of Outlook Care's response to the coroner, noting changes across their remaining nine locations including review of missing person policy, training for staff, additional risk assessments and spot checks on community visits, and will request and review evidence of completion of these actions. The London Borough of Waltham Forest explains its processes for monitoring commissioned supported living services and managing parks/open spaces. They state that the support worker was not employed or commissioned by them. They outline referral pathways for vulnerable adults, rough sleeping monitoring, and vegetation management but do not commit to specific changes. The Metropolitan Police state that they have been unable to identify any other deaths in the area that would suggest any specific or ongoing risk to public safety, or significant criminal activity. They confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping and have increased engagement with local residents to encourage reporting of rough sleeping.

Noted (AI summary) NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for young people up to 25, and existing guidance for GPs. Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information sharing, and safeguarding training as part of their professional training.