Surrey

Noted (AI summary) The DHSC will explore with MHRA and NHSE raising awareness of angiosarcoma following radiation with patients and clinicians. They note that surveillance guidance for angiosarcoma may do more harm than benefit. The RCN supports the coroner's concerns regarding lack of guidance and pathways for radiation induced sarcoma, implants, and the current surveillance period. However, as a professional body, they do not comment on individual cases. Ashford and St Peters Hospitals NHS Foundation Trust is developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop Clinic that will outline guidelines for patient follow-up care, including accommodating patients requiring earlier follow-up in some circumstances. The RCR has tasked the authors of their 'Guidance on screening and symptomatic breast imaging' to consider the coroner's concerns during the current review and ensure all modalities are considered.

Noted (AI summary) The Royal Pharmaceutical Society explains that the BNF provides a general overview and may not include all information necessary for prescribing, recommending referral to a specialist for bipolar disorder. They will continue to monitor for additional information around the management of bipolar disorder for future updates. BMJ acknowledges the coroner's concerns regarding BMJ Best Practice's content on bipolar disorder treatment. They state that the tool is a reference for medical professionals and that content is regularly reviewed and updated, but the decision on treatment remains with the prescribing clinician. They highlight the importance of consulting multiple sources and checking product information sheets for medications. NICE acknowledges the coroner's concerns regarding their bipolar disorder guideline (CG185) and its consideration of the two polarities of bipolar disorder in long-term treatment. They will discuss this area with their topic experts and review any new evidence, updating recommendations if necessary.

Noted (AI summary) Surrey County Council acknowledges the coroner's concerns regarding vegetation encroachment and inspection frequency. They state that pavements are for pedestrians, not cyclists, and that the inspection regime is in line with their responsibilities and national guidance. They will, however, remind the inspection team to consider the risk to vulnerable users posed by debris.

Noted (AI summary) The Food Standards Agency will raise the coroner's report at the next cross-government Food Supplements Working Group and contact relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. Save on Supplements Ltd expresses condolences and states it complies with applicable law, provides information on its website and packaging for safe consumption and reviewed its operations following the inquest. It will consider implementing changes if the regulatory landscape changes. The Department of Health and Social Care discussed the issues raised in the PFD report at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised. They have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.

Noted (AI summary) NHS England highlights the National Care Records Service (NCRS) and Shared Care Records, aiming for national interoperability between all Shared Care Records in England by March 2025 to improve information sharing. Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council clarify the purpose of the SCARF process and highlight existing crisis support services. A project group will be carrying out a detailed review of their cross-agency SCARF process. Surrey Police acknowledges the PFD report but notes that no specific issues were raised in relation to their force, however they will share the findings amongst relevant teams.

Noted (AI summary) EMIS reviewed its EMIS Web system and believes no software developments are required beyond existing functionality. They offer further training to the Practice on optimal use of the system.

Noted (AI summary) South East Coast Ambulance Service NHS Foundation Trust acknowledges concerns about operating at Stage 4 of its Surge Management Plan and outlines factors contributing to increased demand and changes in patient profiles. It states they will continue to work with partners on local and national programmes and a full system-wide review is required. The Department of Health and Social Care highlights its 'Delivery plan for recovering urgent and emergency care services', investments in ambulance workforce, and funding to improve patient flow. They report improvements in ambulance response times nationally and in the SECAmb region, and improvements in patient handover times.

Noted (AI summary) The Home Office, after consulting with the Department for Health and Social Care, believes that appropriate measures are already in place to reduce the risk of accidents involving liquid morphine and has no plans to introduce additional controls. NICE believes its existing guideline [NG46] on controlled drugs: safe use and management is sufficient, including recommendations for healthcare professionals to advise patients on safe storage and appropriate use. The MHRA will work with marketing authorisation holders to update product information for Oramorph, highlighting the need for secure storage and supervision after dilution.

Noted (AI summary) The Department for Transport acknowledges the concerns and notes that National Highways is responsible for the safe management of the Strategic Road Network and is taking actions to reduce risks of future collisions. DfT officials will continue to work with National Highways on the points raised. Connect Plus outlines enhanced measures being implemented, including drainage system cleaning, gully cleaning frequency increases, and safety barrier upgrades. They will also deliver a comprehensive plan for risk management including a cost benefit analysis, a review of carriageway resurfacing, investigation of illuminated warning signs, and a verge review. National Highways has installed a vehicle restraint system at the location of the fatal collision. They have also commissioned an independent review of the drainage system and are considering the viability of reprofiling the carriageway.