London (South)

Noted (AI summary) The council disputes the coroner's concern that its staff could not access records, stating that the records were available, and a review of care arrangements was carried out with awareness of the assessment. It also states that its Careline service acted upon learning from the events leading up to the deaths of Mr and Mrs Cleall.

Noted (AI summary) NHS England is committed to improving Electronic Patient Records (EPRs) across all NHS Trusts and has provided funding to ensure all NHS Trusts have an EPR implemented. An updated MHLT policy outlines the required documentation the MHLT will provide to acute trusts. CQC acknowledges the concerns raised, and states how they will be reviewed via their internal Specific Incidents Guidance (SIG) and that they will continue to monitor the trusts in line with their internal processes and methodology.

Noted (AI summary) The Metropolitan Police Service will deliver learning to staff and officers highlighting the importance of strict location sharing and compliance with standard operating procedures. Surrey Police reviewed records of calls and concluded that calls were handled correctly and promptly passed to the MPS. They agree with MPS that there was no failure in communication between Surrey Police and MPS.

Noted (AI summary) NHS England acknowledges the concerns raised in the report and refers to the SEL ICB's review of the case and the local authority's commissioning of drug and alcohol rehabilitation services. It also mentions the Regulation 28 Working Group which shares learnings from PFD reports across the NHS. DHSC acknowledges the concerns, outlines commissioning responsibilities for drug and alcohol services, and notes the existence of relevant NICE guidance and quality standards. They mention a Pan-London Inpatient Detoxification Programme and ongoing work to develop sustainable inpatient detoxification provision in London. The Ministry of Housing, Communities & Local Government states that they will not be responding to the report as officials do not consider that there is a specific policy angle here for them to respond to, and that the Department for Health and Social Care will be the lead Department responding to this report.

Noted (AI summary) NHS England highlights increased access to CYPMH services, with 758,000 children and young people receiving support in the 12 months to January 2024. They cite a 46% increase in the CYPMH workforce since January 2019 and mention the NHS Long Term Plan's ambition for 100% access to specialist support. They also note discussion of all PFD reports by a working group. The DHSC acknowledges concerns about long waiting times for assessment and treatment in children and young people’s mental health services, and the importance of early intervention and support. They highlight the government's plans to increase mental health staff and improve access to services, and state NHS England will address concerns about the “keeping in touch team”.

Noted (AI summary) NHS England has worked with South London and Maudsley NHS Foundation Trust, who have identified dual diagnosis leads, established a CAMHS Dual Diagnosis forum, incorporated learning from Serious Incidents into team meetings, and are holding briefing sessions on AUDIT completion requirements. All reports received are discussed by the Regulation 28 Working Group. The Department of Health and Social Care acknowledges the concerns and refers to NHS England's response. It also mentions national initiatives for mental health and substance misuse services, including increased funding and commissioning quality standards.

Noted (AI summary) Transport for London has already procured, developed, and installed a bespoke Physical Prevention of Overspeed System (PPOS) on the London Tram network, reducing the risk of overturning by 76%. They are also investigating the feasibility of strengthening tram doors and will incorporate learnings into future fleet specifications. Bombardier Transportation (now Alstom) has completed a door vulnerability assessment, performed design reviews for current and future tram door systems, and engaged with suppliers regarding enhancements. They plan to finalize improvement actions and recommendations for door strengthening for both in-service and new tram fleets by March 2022, and engage with authorities to review UK regulation for light rail doors by April 2022. Tram Operations Ltd is already a member of CIRAS (Confidential Reporting for Safety) for anonymous staff reporting and publicises this to staff. Regarding passenger ejection through doors, they confirm they do not own the trams but welcome discussions with London Trams and would support implementation of strengthening if feasible. Transport Focus clarifies its limited remit and resources to initiate a centrally funded national tram passenger safety group. They state they will engage with operators on passenger safety issues brought to their notice and support any such group initiated by another body. The Department for Transport reports that the Light Rail Safety and Standards Board (LRSSB) has published guidance on driver inattention and speed management, and all tram networks in England now subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). DfT is also consulting on establishing a national tram safety group and supports LRSSB's planned work on automatic braking systems, door strengthening standards, and promoting CIRAS. The LRSSB has published new Light Rail Guidance on Driver Inattention (LG3) and Light Rail Standards on Speed Management Systems (LS4), incorporating RAIB recommendations. They have also commissioned a trial of specific technology for driver inattention and speed management, with outcomes expected by January 2022. The Light Rail Safety and Standards Board confirms that all seven UK tramways already subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). LRSSB further plans to produce a tramway-specific guidance note and communication campaign to promote the benefits of such schemes to front-line staff by March 2022. The Light Rail Safety and Standards Board is engaging with European Standards working groups to inform regulation on tram door security and crashworthiness, and plans to consult with TfL/London Trams to determine remedial actions. LRSSB will then publish a briefing or guidance note for the sector, with timelines to be confirmed.

Noted (AI summary) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.