Inner North London

Noted (AI summary) • HMPPS stated it is committed to tackling the ingress of drugs and other contraband into prisons. • All adult male closed prisons are equipped with X-ray body scanners. • All public sector prisons have been provided with trace detection equipment.

Noted (AI summary) • Operational reminders have been issued reminding Custody Officers to ensure medical requests are made. • A new protocol for 'case finding' was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant and checks if there are any detainees who may have unmet medical needs.

Noted (AI summary) The ABPI, as a trade association without regulatory authority, has made the originator company, Bristol Myers Squibb (BMS), aware of the coroner's report and concerns regarding apixaban patient safety information and labelling. MedicinesUK states its member companies will comply with any future changes to product information regarding anticoagulants and head trauma warnings, should such changes be required by the MHRA. The MHRA has completed a preliminary assessment and initiated a full review across all Direct Oral Anticoagulants (DOACs) and warfarin regarding patient information leaflet warnings for head trauma, with plans to seek expert advice on potential updates.

Noted (AI summary) Total Security Services clarifies that its security officer was not employed as a first-aider and it's not contractually required by Tesco for security officers to provide first aid. The company expects its employees to follow their SIA licence training and will conduct monthly audits to ensure that all its employees continue to hold valid licences that have neither been revoked nor expired. The Security Industry Authority (SIA) investigated the training and conduct of the security operative and Total Security Services Limited, and will consider regulatory action if necessary. They have also offered expert witness assistance to coroners in relevant inquests. Tesco will deliver "Appointed Person" training to approximately 30,000 UK store management colleagues starting December 1, 2025, with completion by February 28, 2026. This training will provide managers with the skills to relay information to Ambulance Control, follow their instructions, and administer basic first aid when directed.

Noted (AI summary) The Royal College of Psychiatrists will remind members to adhere to NICE guidelines when prescribing ADHD medication and will discuss the case at a webinar on prescribing errors. They also highlight existing guidelines and resources and mention the TIMESPAN consortium is developing consensus recommendations for ADHD patients with increased cardio-metabolic risks. The Department of Health and Social Care acknowledges the concerns raised and states that the MHRA publishes guidance, the BNF provides evidence-based information, and professional bodies and regulators hold prescribers to account.

Noted (AI summary) Mountfield Surgery confirms they are unable to provide IV rehydration at home due to clinical safety concerns and the scope of primary care services. They will raise the matter with local NHS partners to review community subcutaneous rehydration pathways and engage with their local Primary Care Network. CLCH states that IV rehydration is typically provided in a hospital setting, and a doctor would need to prescribe the fluids and equipment; the SPOA doctor did not decide IV fluid treatment was needed in this instance. In severely dehydrated cases, the quickest and most effective treatment would be hospital admission or, if the patient prefers to stay at home, a GP could prescribe IV fluids to be administered by the rapid response team.

Noted (AI summary) NHS England highlights existing national guidance and safety alerts on anti-ligature measures, and the North London Mental Health Partnership's incident response with recommendations, and will continue to engage with local teams for updates. The organisation also notes that all reports received are discussed by the Regulation 28 Working Group. The Department acknowledges the concerns and references existing guidance from the Care Quality Commission and NHS England on anti-ligature measures, as well as ongoing work via NHS England's mental health inpatient quality transformation programme and the national Suicide Prevention Strategy.

Noted (AI summary) RCEM highlights existing standards requiring paediatric early warning scores, results from national audits, involvement in designing a revised paediatric early warning score, and advocacy for better staffing and resources. The RCN states it is not the regulator for nurses and has no remit to address the concerns, but offers learning resources and highlights its work on the National Early Warning System (NEWS2) Observations Tracking Programme and collaboration with RCPCH on emergency care standards. The Trust has implemented training and induction enhancements, updated the Emergency Department Nurse in Charge checklist, mandated completion of an ED Paediatric Discharge Checklist, and is undertaking ongoing monitoring and training to improve standards of practice. The RCPCH is in the process of updating its Facing the Future Standards for Emergency Care, to be published later in 2025, which will clarify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.

Noted (AI summary) The DHSC has a surveillance system in place to track changing drug markets and harms, including toxicology results from coroner post-mortem toxicology labs and implemented a structured process for assessing the threat posed by synthetic opioids and other drugs. DHSC has published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required. FRANK website has a page providing detailed information on when and how to use naloxone. The ACMD acknowledges the concerns about nitazenes in vapes and notes its existing reports and recommendations on the issue, including improved toxicology and testing, and improved information for health professionals and the general public; it will raise the concerns at an upcoming meeting.

Noted (AI summary) Islington Council expresses condolences and provides background on the inquest hearing, including limitations on evidence presented, and includes details of their income and expenditure assessment process for housing applicants.