East London

Noted (AI summary) The Home Office describes the Police National Database and its use, noting it is a top priority to tackle violence against women and girls and highlighting the new National Policing Centre for VAWG and Public Protection.

Noted (AI summary) The response details that all Integrated Care Boards are expected to expand local provision by commissioning NHS Talking Therapies services that are integrated into physical health pathways. The practice will also send out the Waltham Forest Talking therapy (IAPT) website details and phone number to all of its patients with chronic diseases, and with stress. The response only contains contact details for Queen Mary University of London's Clinical Effectiveness Group.

Noted (AI summary) The Department of Health and Social Care acknowledges the report and expresses condolences. They state that the Department of Education has oversight for child social care and is best placed to comment on the concerns raised. Social Work England acknowledges the coroner's concerns and is reviewing documentation and recordings from the inquest to determine if there are reasonable grounds to investigate any of the individual social worker’s actions, and will contact relevant parties to gather further information. The London Borough of Newham has re-evaluated internal policies and procedures and made significant changes and improvements, including a review of complaints, annual audits focusing on single parents with limited networks, and a review of the Supervision Policy, alongside MAGPIE and Praxis. An NRPF Plan template has been introduced following Child and Family Assessments, and the NRPF Panel Form has been embedded in their ICS system. NPAS will use footage from the incident as a case study/training tool to encourage Tactical Flight Officers to think beyond initial information in similar search scenarios, starting with the next training course on February 14th.

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) 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) 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.