Inner West London

Action Planned (AI summary) CNWL NHS Trust has clarified report request procedures with HMPPS, ensured report requests are communicated to consultants promptly, updated care plan templates to include release planning, audited CPA meetings to improve attendance, and launched an Offender Care Transformation Board to reduce self-harm and avoid unexpected deaths. HMPPS is reviewing procedures for fitness to plead reports, developing a framework to support families with prison visits (due in 2018), implementing recommendations from the Farmer Report on family ties, and implementing a new model of offender management in custody by March 2019 to ensure external agencies are notified of a prisoner's release.

Action Planned (AI summary) • Greater Manchester Police (GMP) is investing in technology to replace existing systems with one user experience to improve information management and sharing. • Mobile technology is being distributed to operational staff to provide direct access to GMP IT systems for improved information access and decision-making. • GMP is undertaking a procurement, design, and testing process before implementation, scheduled for late 2017.

Action Planned (AI summary) The Department of Health acknowledged concerns about BiPAP machine design and power supply resilience. It will review relevant sections of the Hospital Technical Memorandum (HTM) as part of its wider technical guidance programme and consider the issue of alerts, but believes current HTM guidance is adequate. St George's will install a UPS/IPS backup system in the Richmond ADU, with completion expected in summer 2016, to address power supply concerns. Nursing staff are also undertaking twice-weekly checks of emergency call bell systems.

Action Planned (AI summary) TfL plans to publish proposals for improved traffic arrangements around London Bridge and will investigate the feasibility of a Cycle Superhighway across London Bridge starting in 2016, incorporating public consultation. They will also install an additional pair of speed repeater signs on the north side of the bridge and consider spacing of repeater signs.

Action Planned (AI summary) The Department for Education intends to issue additional guidance to the early years sector in 2015 under the EYFS banner, principally about what constitutes good paediatric first aid provision in settings. This guidance will point out the dangers of using raw jelly in play with young children without sufficient supervision as an example of a choking hazard, and they will review first aid requirements. Ofsted will disseminate the inquest findings to Ofsted and contracted inspectors of EY provisions, ensuring they are aware of the risks of using raw jelly in activities during inspections of EYFS compliance. They are also liaising with the Local Government Association to discuss the report and ensure appropriate warnings are communicated to settings. The Food Standards Agency will forward information about the risks of raw jelly cubes to local authority environmental health services and industry manufacturing/retail trade bodies. They will also forward the coroner's report to the Department of Health for consideration in relation to early years food advice to parents.