Inner North London

Action Planned (AI summary) The Royal Free London NHS Foundation Trust plans to implement several measures by June 2025, including shared learning presentations, PPU escalation process reviews, and an education program for deteriorating patient recognition. They will also reiterate documentation standards, review seven-day services, and create a standardized board rounds process.

Action Planned (AI summary) The North London NHS Foundation Trust outlines changes to Olanzapine depot injection procedures: patients will receive clearer risk information; staff delivering post-injection observations will not be distracted; and alternatives to Olanzapine depot will be explored for patients who refuse vital signs checks.

Action Planned (AI summary) DSIT is working with Ofcom to implement the Online Safety Act 2023, which tackles illegal and legal forms of online suicide content. The Act requires services to assess the risk of users encountering illegal content and to remove legal content prohibited in their terms of service. Ofcom is providing guidance to services on identifying content that illegally encourages or assists suicide, and search providers have duties to remove or lower the ranking of illegal suicide content. Ofcom is working with services to promote compliance and will take enforcement action if needed, taking evidence from coroner's reports into account.

Action Planned (AI summary) The Borough will publish a message in the January edition of 'Love Hackney' reminding residents not to use steps/ladders on balconies and to contact the repairs centre for guttering/pipework issues. They also conducted a survey of the external elements and elevations, focusing on surface water drainage serving the balconies, and found no defects except for temporary tape applied to one balcony.

Action Planned (AI summary) Barts Health NHS Trust is undertaking a Patient Safety Incident Investigation (PSII) to identify opportunities for learning and improvement following a patient fall, and will use the findings to identify actions to improve patient safety, recording actions on Datix.

Action Planned (AI summary) The Trust will continue to assure training standards around ACCT are sustained, will continue to participate in ACCT reviews in accordance with its operational policy, and will implement a learning event for the Unscheduled Care Team workers and clinicians. The learning event will focus on the message, ‘if in doubt, implement an ACCT’.

Action Planned (AI summary) UKHSA will undertake a risk assessment in collaboration with the clinical team treating a case to determine whether additional contact should be made with the next of kin when a case is known to die during investigation; contact details of the UKHSA regional team will be shared with immediate family so they can contact the regional team if they have any questions or would like to provide any further information. UCLH will reinforce how they make relevant infection information available to patients and their next of kin and will reflect on this case. They will also endeavour to document health protection team contact details in their electronic health records system.

Action Planned (AI summary) The MHCLG will write to the local authorities concerned to remind them of their statutory duties, and the government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests.

Action Planned (AI summary) Peabody has implemented emergency temporary fencing and developed proposals for permanent safety railings at the canal edge, while working with the London Borough of Islington and CRT/CIC for required approvals. They have also strengthened internal policies and procedures relating to resident safety and reporting concerns. Islington Council is working with Peabody on a planning application for safety fencing around the canal side area of the Crest Buildings development. Urban design lessons from this incident have been shared with Development Management Officers, and a planning application for another canal side residential development includes fencing. The Mayor of London will consider the concerns raised in the PFD report through his review of the London Plan, with public consultation planned for the second half of 2025 and adoption of the revised Plan in 2027. Any changes made to the NPPF by the government will also be considered. The government published an updated NPPF on 12 December 2024 that includes additional policy to consider the safety of children and other vulnerable users in proximity to open water, railways and other potential hazards.

Action Planned (AI summary) The IOPC recommends that the British Transport Police (BTP) should explore opportunities to raise awareness of the Vulnerability Assessment Framework (VAF), outside of the Public Protection and Vulnerability training programme. British Transport Police (BTP) will be implementing a number of changes in response to the Prevention of Future Deaths report. These include piloting joint response vehicles (JRV) with mental health nurses, improving Section 136 and 297 detentions, delivering new mental health and wellbeing training and incorporating both clinical supervision and police staff with mental health expertise within HaRT.