Surrey

Noted (AI summary) Barchester Healthcare has implemented widespread changes at Windmill Manor Care Home, including improved record keeping with the 'Enable' e-care system, clinical governance reviews, and General and Regional Manager oversight. Wound assessments are now completed electronically, and staff are supported by a Clinical Development Nurse.

Noted (AI summary) NHS England acknowledges concerns around the transfer of mental health patients back to primary care and highlights the Personalised Care Framework (PCF) which sets out core aspects of care and emphasizes the responsibility of services to support safe transitions. It also describes existing procedures for care planning meetings and information sharing during discharge. The Department for Health and Social Care acknowledges the concerns and states that NHS England has developed draft guidance, the Personalised Care Framework (PCF), to support local systems in improving the continuity of care for people with mental health needs. It emphasizes the responsibilities of services to support safe transitions between secondary and primary care.

Noted (AI summary) The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations.

Noted (AI summary) The nursing home acknowledges the report and states improvements have been ongoing since the incident. They refer to a CQC inspection report from January 2024 detailing actions taken since a previous inspection.

Noted (AI summary) The Home Office is researching the availability of the substance in question and supports the DHSC in delivering the Suicide Prevention Strategy for England. Border Force has issued guidance to officers about control actions regarding goods at the border that may assist with suicide. The Department of Health and Social Care acknowledges the concerns regarding the purchase of sodium nitrite but states that the responsibility for these concerns sits within another organization.

Noted (AI summary) NHS England is developing a Reasonable Adjustment Digital Flag to record information about patients, including if they are autistic or have a learning disability, and their reasonable adjustment needs. The RCEM highlights existing resources such as the Learning Disabilities Toolkit and involvement in the development of the ED version of the national paediatric early warning system (nPEWS). They feel unable to comment on inpatient care and state provision of learning disability nurses is outside their remit. CQC acknowledges the concerns but states that commenting on the specific guidance is outside of their regulatory scope. They are reviewing the case in line with their incident guidelines. The Trust is developing a Learning Disability Admission Checklist to provide prompts for staff in Emergency Departments and establish a system to record reasonable adjustments, planned for Quarter 3, 2025. RCPCH's revised Facing the Future: Emergency Care Standards will be published in Autumn 2025 and shared with relevant professionals, and will include a standard on EDs having a lead professional for CYP with complex needs and access to advice from a Learning Disability Liaison Nurse. The Department highlights the upcoming 10-Year Health Plan which will improve awareness of learning disability and autism within the health and social care system. It also references Martha's Rule which gives patients and their families the right to initiate a rapid review of their case.

Noted (AI summary) NHS England acknowledges concerns about public understanding of Physician Associates (PAs). It highlights the Leng Review of PA and AA professions, the establishment of PA title by law, and existing guidance on PA deployment. The RCEM issued new guidance moving PAs to Tier 2 on the ED rota. The Trust implemented the changes immediately, and PAs at the Trust are also now trained to state that they are not a doctor. The RCEM issued a position statement in June 2024 regarding Physician Associates which included supervised practice, public awareness, undifferentiated patients, and regulation. RCEM has worked with the national emergency laparotomy audit project (NELA) for several years to improve the care of patients who require an emergency laparotomy (abdominal operation). The CQC acknowledges the coroner's concerns regarding Physician Associates and rapid sequence induction but states that some points are outside of their regulatory scope. They will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of their ongoing monitoring and engagement with them. DHSC acknowledges concerns regarding Physician Associates, rapid sequence induction, and guidelines. They highlight that healthcare professionals must practice within their competence. NHSE has issued guidance on the deployment of PAs and AAs in the NHS and NHS Employers has also published guidance for employers. The Association of Anaesthetists and RCOA Difficult Airways Society address concerns raised and reference existing guidelines; they state that the topic of rapid sequence induction (RSI) is controversial and best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. The GMC highlights its new powers to regulate PAs and AAs and states that it is developing website materials, due to be published in Spring, to support doctors who are supervising PAs. Surrey & Sussex Healthcare NHS Trust acknowledges concerns regarding public understanding of Physician Associates, rapid sequence induction, and the use of cricoid pressure. It states PAs wear different coloured scrubs, and are trained to introduce themselves as PAs. They communicated the importance of cricoid pressure to the anaesthetic team and trainees, and that modified TIVA technique is used with a predetermined dose of propofol and muscle relaxant. The RCP acknowledges concerns about the safe deployment of PAs and notes that the Faculty of Physician Associates was dissolved on 31 December 2024. It highlights concerns regarding regulation, scope of practice and supervision and states they have now delivered the results of a working group on PA and have submitted their findings to the Leng review alongside a submission from their resident doctors.

Noted (AI summary) NHS England acknowledges concerns and outlines existing oversight mechanisms, offering support to connect TCT's clinical team to specialists within the NHS and supporting TCT in connecting within the local integrated care system to improve flow to clinical appointments. CQC states that The Children's Trust (TCT) have strengthened their frequency of monitoring policy and increased their audits of the implementation of this policy; have a Frequency of Monitoring Policy in place since July 2022 which continues to be reviewed and updated. CQC have seen evidence of a strengthened learning culture at TCT through inspection and routine engagement conversations. The DHSC acknowledges the concerns raised in the report and states that they have sought assurances from the CQC and NHS England that responses are being prepared to address concerns respective to each organisation. They highlight ongoing monitoring by the CQC and clarify commissioning responsibilities. The Children's Trust has revised its Frequency of Monitoring Policy, enhanced clinical governance frameworks, and strengthened integration with NHS services following the death of Mia Gauci-Lamport.

Noted (AI summary) Surrey County Council is preparing a communication to all Surrey education providers to clarify that there is no financial threshold for requesting an EHCNA, reinforcing the statutory position under the Children and Families Act 2014. The Department for Education acknowledges the concerns, highlights existing guidance on safeguarding and EHCPs, and notes ongoing monitoring of Surrey County Council's SEND arrangements, keeping the safeguarding guidance under review.

Noted (AI summary) The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level. NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care.

Noted (AI summary) Surrey Council explains that the SCARF process is not designed for emergency referrals and that a clear process exists for officers to contact the Emergency Duty Team out of hours. The Trust updated its website with referral routes, enhanced collaboration with families, and revised the SBAR tool to include carer/family views. They have also implemented mandatory training for staff on the referral pathway to mental health services, with 86% completion to date and the remainder scheduled for completion soon. Surrey Police is reminding all officers to undertake research as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves; this message will be conveyed via force emails and a reminder on the daily briefing to response officers.

Noted (AI summary) NHS England acknowledges the coroner's concerns but states that NICE is the appropriate body to provide clinical guidance. NHS England will review NICE's response and consider any resultant actions, while noting the need for individualised care in such cases. They are also gathering information on a delay in reporting a CT scan result. NICE acknowledges the lack of specific guidance on restarting anticoagulants after traumatic intracranial haemorrhage. NICE will consider the issues raised through their guidelines surveillance process and discuss a consensus statement with relevant specialist societies.