Inner West London

Noted (AI summary) The CQC conducted inspections of Lisson Grove Health Centre but ultimately did not find concerns in the areas identified in the prevention of future death report. They rated the health centre 'Good' overall.

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 Trust provides an account of their involvement with the patient's case, including the referral and assessment process for a possible co-morbid eating disorder, and explains why a full ASD assessment was not carried out by their service. The Department of Health and Social Care acknowledges concerns about outcomes for young people on the autistic spectrum and is launching a comprehensive review of the autism strategy, expected to report in November 2019, which will include a national call for evidence.

Noted (AI summary) NHS England acknowledges concerns about online availability of potentially dangerous drugs like Tramadol, but states that the death was not a result of NHS services. They are working with other health regulators like CQC and MHRA and remain committed to improving the safety of controlled drugs and online prescribing.

Noted (AI summary) Whirlpool outlines its product safety processes, including senior leadership oversight, and highlights the existence of a freephone number and prominent stickers on new products encouraging registration. They are also leading discussions within the industry on improving consumer awareness of the 'Register My Appliance' site. The Department highlights the launch of a new Code of Practice on product recalls (PAS 7100) and the development of a comprehensive digital service for consumer product safety information. They also support the 'Register My Appliance' site and are meeting with Whirlpool UK regarding their recall processes. The CTSI states it is a professional body without powers to investigate and the matter is for local authority trading standards departments. They also highlight a workforce survey showing cuts to trading standards services.

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.