Inner South London

Action Planned (AI summary) • NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings through the Culture of Care national programme. • NHS England launched Staying safe from suicide guidance in June 2025 to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts.

Action Planned (AI summary) A cross-trust working group is being established to improve the use of the EPIC system, focusing on issues such as copy/paste practices and care plan updates. The group will design quality improvement projects, review EPIC training, and monitor the impact of changes.

Action Planned (AI summary) The RCVS will consider adding a requirement for practices to have individualised suicide prevention plans, review legislative requirements for schedule 2 CDs, review guidance on returning CDs when off duty, and explore methods of communicating legal and regulatory requirements relating to lethal medicines to the profession. They will also continue to engage with the Home Office on additional safeguards.

Action Planned (AI summary) NHS England acknowledges concerns and will work with the MHRA to establish a communication Memorandum of Understanding to share learning from serious incidents related to aseptic medicines preparation/manufacture. They also note that all reports received are discussed by the Regulation 28 Working Group to share learnings across the NHS. CQC will review oversight of independent sector providers not subject to iQAAPS audits during 2025-26. It will also use the iQAAPS dashboard to discuss organization-specific risks with NHS trusts during 2025-26. NHS England has strengthened guidance on aseptic preparation of medicines and auditing and introduced strengthened oversight and external quality audits via the iQAAPS web-based quality reporting system. NHS England, MHRA and CQC will implement a 2-way information sharing agreement at organisational level to share learning of serious incidents related to aseptic medicines by end of June 2025. DHSC will meet with CQC, NHS England and MHRA to ensure that the actions of each organisation to address concerns are complementary, coordinated and completed. The MHRA will publish an update to the sector detailing issues raised by this case and our intentions to address the concerns (by the end of March 2025), agree and implement a memorandum of Understanding (MoU) with NHSE for routine updates and also the dissemination of ad hoc learnings from incidents (by end of June 2025). The MHRA will inform devolved governments of this requirement to improve information exchange as soon as practical and agree an approach in line with that for the NHSE MoU (by end of September 2025).

Action Planned (AI summary) The practice will clarify if things have been sorted in future and possibly call Adult Social Care. They have discussed this with practice management and the clinical lead. The Trust has taken or is planning multiple actions including reviewing the policy for patients who repeatedly do not attend appointments, staff wellbeing initiatives, enhancing governance meetings, and ensuring client contact information is accurate and up to date in RiO.

Action Planned (AI summary) NHS England has engaged with NICE to strengthen cautions around Propranolol use and will issue communications to GPs reiterating that NICE does not recommend Propranolol as a treatment option for anxiety, and emphasizing the risks involved in its administration. They are also engaging with the MHRA.

Action Planned (AI summary) The Department for Science, Innovation and Technology acknowledges the coroner's concerns and states that the Online Safety Act 2023 will place duties on tech companies to protect users online, especially children, overseen by Ofcom. It also details Ofcom's enforcement powers, including business disruption measures for non-compliant services. Ofcom outlines its role in implementing the Online Safety Act 2023, including developing codes of practice, working with industry to secure higher protection for children, and taking enforcement action against non-compliant services. They will consider the evidence in the report as they continue policy development.

Action Planned (AI summary) The CAA acknowledges the challenges of mountain flying and states it will publish relevant guidance on its website by 31 July 2024, and a Safety Sense Leaflet on mountain flying by 31 December 2024.

Action Planned (AI summary) Lewisham and Greenwich NHS Trust provided education sessions on escalating low and high temperatures in neonates, reinforced the Kaiser Permanente pathway, and included Kaiser scoring assessment in neonatal notes. The Royal College of Paediatrics and Child Health will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and at the next RCPCH Clinical Quality in Practice committee.

Action Planned (AI summary) NHS England is undertaking national work by paediatric experts to reduce the likelihood of incorrect oral morphine preparations being prescribed, including a specials formulary, standardisation of strengths of paediatric oral liquids, national guidelines, and a national approach to GP prescribing systems. The London region Controlled Drugs Accountable Officer will discuss this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans.