South Yorkshire (West)

Noted (AI summary) Sheffield Children's NHS Foundation Trust CEO expressed apologies to the family and outlined the various actions taken, including a meeting with the family and a presentation to the Trust Board to emphasize learnings from the case. Sheffield Children's NHS Foundation Trust has improved induction training for junior doctors, providing information on when to escalate concerns to senior staff, particularly regarding reattenders, fever, chicken pox and sepsis. They have reminded primary care of the current referral system and will ensure patients arriving with GP letters are seen by the appropriate team.

Noted (AI summary) The Trust offers condolences and provides context on Intensive Home-based Treatment Teams (IHBTT), clarifying their role and approach to risk assessment, particularly regarding communication with family members. They state that the partner's contact was appropriately considered and shared with the visiting practitioner.

Noted (AI summary) Sheffield Health & Social Care NHS Foundation Trust outlines a plan to develop a protocol for working with older adults with a forensic history, ensure thorough risk assessments when removing a service user from detention, improve communication with service users and families, ensure complex clinical decisions are multidisciplinary, and deliver online training on the Mental Health Act. The Government Legal Department, on behalf of the Probation Service, acknowledges the concerns but states it's a matter for the sentencing Judge to determine Restriction Orders. They will obtain the Court transcript of Mrs Grayson's sentencing hearing and share concerns with the Ministry of Justice colleagues in the Mental Health Caseworker team.

Noted (AI summary) Yorkshire Ambulance Service NHS Trust will audit patients treated at home to gather feedback on information provided, review the PIL template content, conduct spot audits of care plans, launch a communications campaign for staff on detailed care plans for non-conveyance, and develop tick-box indicators on the EPR. The future intention is to embed the PIL content into the EPR and email it to the patient and their primary care provider. The National Medical Director describes existing NHS Pathways triage processes, including the use of a standard set of questions and validation of information by clinicians. They state that shared care records allow clinicians to access information on long-term conditions, medical history, medications, and allergies.

Noted (AI summary) Human Race acknowledges the coroner's feedback regarding the tragic accident, but maintains that the events were not reasonably foreseeable. The company states it will take the comments on board when planning and risk assessing future events, but emphasizes the difficulty of anticipating all potential eventualities.