Nottingham and Nottinghamshire

Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS has worked with partners to develop a Sepsis Observation Safety Net, implemented enhanced clinical review processes prior to call transfer, and ceased manual ITK push transfers to NEMS. NEMS has stopped manually pushing calls, implemented a standardised Sepsis Observation Safety Net, and provided additional training and resources to clinicians; furthermore data sharing agreements are in place to share discharge summaries and admission avoidance alerts. The ICB facilitated a system wide After-Action Review, EMAS have stopped the ITK push of calls, a review and redefinition of the existing UCCH service specification has occurred, and analytics team have developed the ability to join up multiple data sets to understand patient journeys.

Action Planned (AI summary) The ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across all relevant partners, and improvement initiatives identified by the review will be taken through and monitored for assurance within the existing governance for the relevant systems. EMAS clinicians now review all available information prior to transferring calls, and clinically assessed calls are no longer pushed to any EMAS Clinical Assessment Service (CAS). Manual ITK push transfers to NEMS have ceased. NEMS implemented changes to clinical practice and referral processes, including revised sepsis screening tools, enhanced clinical oversight, and improved information sharing with system partners. They have also invested in staff training and equipment to improve the management of complex patient presentations. The ICB facilitated a system-wide After-Action Review, reviewed and redefined the UCCH service specification, and developed the ability to join up multiple data sets to understand the patient journey across the pathway. They also committed to sharing PFD learning and assurance actions across multiple committees and processes.

Action Planned (AI summary) The Trust is undertaking an Acute Aortic Dissection Improvement project, involving multiple teams and collaboration with the East Midlands Aortic Network, to improve early detection of the condition.

Action Planned (AI summary) The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. The NPCC clinical panel is reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine regarding Acute Behavioural Disturbance. The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. The Department and NHS England are finalising the Co-occurring Mental Health and Substance Use Delivery framework to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.

Action Planned (AI summary) Nottinghamshire Police will be amending their information sharing processes so that PPNs considered suitable for referral to adult social care will be accompanied by PPNs from the previous 12 months that were not previously deemed suitable for sharing, commencing 1st October 2025.

Action Planned (AI summary) The DVLA is considering research and evidence, including evidence presented during the inquest, to inform potential changes to the law that governs driver licensing for those with medical conditions. The Department is also developing its Road Safety Strategy and will set out more details in due course.

Action Planned (AI summary) NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.

Action Planned (AI summary) Nottinghamshire Police is revising its policy to ensure consistent procedures for supporting suspects of relevant offences, irrespective of whether they are arrested or attend voluntarily. The revised policy will include an automatic referral to Liaison and Diversion (healthcare services) and is planned for implementation by 1st March 2025.