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) 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. 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). 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.

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 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) 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.

Action Planned (AI summary) Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. A fortnightly meeting involving all providers has now convened allowing discussion of patients presenting with disability that may be of concern, to facilitate improved care planning and communication. HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently about disability and to improve how they engage with disabled prisoners.

Action Planned (AI summary) Tower Bridge Care Home describes arrangements for diabetic foot clinic attendance, communication with GPs and multidisciplinary meetings, and identifies residents with high needs to the consultant geriatrician for face-to-face reviews, since September 2022. They also describe processes for DNAR (Do Not Attempt Resuscitation) orders and managing capacity issues. The RCGP is working to improve communication between secondary and primary care with colleagues across specialities, and with NHS England and NHS Improvement to improve communication links. King's College Hospital has established a working group to improve consent and MCA assessments, reviewing consent and MCA training programmes, and updated the Trust's consent policy. The Trust also initiated a Trust-wide consent audit in September 2022.

Action Planned (AI summary) HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training for front line court staff to identify and escalate safeguarding concerns. The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff were reminded to adhere to the 'probation risk to self' EQUiP process maps. London Probation published a new thematic Suicide and Self-Harm Performance and Quality Newsletter on 19 January 2022.

Action Planned (AI summary) The MPS will share the report with relevant departments and review training programmes to include expert evidence-based advice on knife carrying and gang membership in domestic abuse risk assessments. A review of CSU resourcing is underway, with findings to be presented to the MPS Management Board in January 2022.

Action Planned (AI summary) DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.