Inner West London

Noted (AI summary) The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019. The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action. The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme.

Noted (AI summary) The Clinical Director is scoping a quality improvement project focusing on family/carer engagement and primary care liaison. A learning event is being organized to share actions and promote reflection. The trust is committed to triangle of care principles and is about to undertake the next round of self-assessments. The Trust is working to produce guidance for GPs on raising concerns and referrals and is looking to strengthen family and carer engagement and primary care liaison. The CCG will review the Trust’s action plan. Cricket Green Medical Practice acknowledges the coroner's report and confirms a Significant Event Analysis (SEA) was undertaken. They note actions the GP practice took and actions the CCG could have utilised. The CCG will review the Trust’s action plan and conduct a learning event.

Noted (AI summary) TfL states they have well established methods to determine grip levels across the Transport for London's Road Network, including cycle superhighways, and implement a comprehensive skid resistance policy. They will be raising the issue of differential skid resistance across a lane with the UK Roads Board.

Noted (AI summary) The London Ambulance Service states that based on their understanding of the call records, no changes to the questions asked of 999 callers would have enabled them to triage the call differently, unless they had been informed that contact with the patient had been lost.

Noted (AI summary) The Department of Health acknowledges the coroner's concerns about EU-trained doctors and refers to the GMC's verification process and hospital observer programs. It notes Health Education England's view that St George's hospital's program is thorough and could be disseminated but states primary responsibility rests with individual employers.

Noted (AI summary) Care UK acknowledges the coroner's concerns regarding access to patient information and describes existing systems for receiving information from GPs, including post-event messages, Special Patient Notes, Summary Care Records, and Coordinate My Care in London. They emphasize that the onus is on the registered GP practice to enable access.