Kent and Medway

Action Planned (AI summary) HMPPS is consulting with clinical experts to develop and issue new written guidance for staff on recognising signs of Acute Behavioural Disturbance (ABD). This guidance aims to ensure officers identify potential medical emergencies and escalate concerns appropriately, in line with updated NHS England Use of Force frameworks.

Action Planned (AI summary) The Trust is revising its Rapid Response Standard Operating Procedure to ensure senior clinical oversight of referrals, revising its CAMS policy, considering a dedicated CAMS workforce, and promoting the use of the Urgent Mental Health Helpline.

Action Planned (AI summary) HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve first-on-scene care, HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff.

Action Planned (AI summary) A Practice Development Nurse (PDN) was appointed in September 2024 to ensure healthcare staff remain current with training and guidance, and the Quality Manager has reviewed and updated policies, communicating their locations to all staff members. SECAmb has several actions planned, including: establishing a Prisons Task and Finish Group, communicating the move away from 'Code Red/Blue' terminology, ensuring clarity around primacy of care, and undertaking a learning needs analysis regarding restraint implications. They will also review the Surrey Safeguarding Adults Board Care of Prisoners into Acute Hospitals guidance. HMPPS has reminded staff at HMP Elmley to request healthcare assistance immediately during any unplanned restraint and Oxleas staff have been reminded of their contractual requirement to remain with the individual throughout the medical emergency. NHS England Health & Justice guidance has been shared with Use of Force Coordinators and will be included in the new HMPPS framework and guidance.

Action Planned (AI summary) East Kent Hospitals NHS Trust is planning improved trend charting in their Electronic Medical Record (EMR) to be installed by the end of September 2025, a communication plan to highlight the importance of clinical documentation, and a trial using the 'Sunrise Mobile' application on a tablet device to facilitate real-time documentation; they also plan to digitize surgical care plan documentation and review LocSSIPs.

Action Planned (AI summary) The clinic has implemented regular weight and height monitoring for patients 65+, flag unintentional weight loss, involve the Primary Care Network's Frailty First Contact Practitioner Dietitian, update referral criteria, ensure patients experiencing rough sleeping are under the care of the Rainbow Centre, update self-neglect policy, and review unexpected deaths in clinical meeting discussions. The Trust has a Nutrition Trust Wide Improvement Plan that includes essential nutrition training for staff, enhanced ward processes for identifying at-risk patients, and improved communication; it will also undertake a multi-professional case note review of the patient's care and treatment in the months preceding her admission.

Action Planned (AI summary) Kent Central Ambulance Service outlines multiple planned actions including: refresher training, distributing Major Operations Procedures (MOPs), retraining staff on contacting the Clinical Line, subscribing to the Purple Guide, and deploying an Event Readiness Checklist.

Action Planned (AI summary) NHS England published a two-year Urgent & Emergency Care Recovery Plan in January 2023 and is collecting weekly data to identify patients waiting over 100 days for discharge, discussing these cases at a weekly National Coordination Centre call and tracking themes through weekly regional engagement meetings. The South East region has also undertaken Quality & Safety visits to EDs to share learning and best practice. The DHSC acknowledges concerns about A&E waiting times, bed capacity and patient experience and highlights the government's commitment to improving services, including an extra £22.6 billion for the NHS in 2025/26. They plan to reform the Better Care Fund, join up health and care services, and publish a 10-Year Health Plan.

Action Planned (AI summary) HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a key worker and that specific cohorts of prisoners at risk of harm or self-harm are identified and supported by trained staff members. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.

Action Planned (AI summary) Oxleas will ensure the healthcare team is aware of relevant policies and that these are shared and discussed, and has updated on-call GP guidance. A review of policies has been completed and shared. HMPPS has issued an order to staff regarding escalating concerns about prisoners under the influence of illicit substances. They are also embedding a process for sharing information about at-risk prisoners with medication in their possession, and are consulting on new guidance around prisoners under the influence.

Action Planned (AI summary) The Department for Education is consulting on changes to the EYFS statutory framework, including a new safer eating section and revisions to PFA requirements. They expect to publish the response to the consultation in autumn this year.

Action Planned (AI summary) Medway Council will programme a safety scheme to investigate potential safety enhancements at and approaching the location of the incident on Maidstone Road. Any amendments will be determined by the appropriate and proper study, delivery timescales dependent on scale of amendments.