Surrey

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) National Trading Standards states that they are unable to act on the issues raised, as product safety does not fall within their remit. They recommend the report be sent to the Office for Product Safety and Standards. The GMC asserts that medical training in the UK equips doctors with the necessary skills to assess complex acute situations, and no further specific training intervention is required for Immersion Pulmonary Oedema at this stage. They describe their role in quality assuring medical education.

Noted (AI summary) NHS England refers to NICE guidance and Clinical Knowledge Summaries for managing febrile seizures, and notes work underway to review training on child death review processes and support for families. They are also considering the Surrey Heartlands Integrated Care System’s Child Death Review and discussing reports to prevent future deaths. The Royal College of Emergency Medicine acknowledges the complex nature of managing febrile seizures and expresses willingness to collaborate with other organizations to develop further evidence-based guidance. The AACE has made medical directors and lead paramedics aware of the circumstances and asked them to review JRCALC guidance and local pathways. They also reminded ambulance trusts of the NASMeD guidance on conveying children by operational ambulance clinicians. NICE believes existing guidance (CG137, replaced by NG217) and Clinical Knowledge Summaries sufficiently cover assessment of febrile seizures. They are participating in system-level discussions with NHS England and the Royal College of Paediatrics and Child Health regarding SUDIC research and action.

Noted (AI summary) NHS England acknowledges the concerns and highlights ongoing work to improve understanding of autism and mental health conditions. They mention mandatory autism training for regulated services and reasonable adjustments required under the Equality Act 2010, and that Surry and Borders Partnership NHS Foundation Trust have undertaken autism spectrum disorder (ASD) awareness training since June 2022.

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) HSE acknowledges the concerns raised, notes the ongoing investigation, and explains the existing notification requirements for construction projects. They clarify that enforcement action, including requiring training, is proportional to the risks and seriousness of the breach and that previous poor performance is taken into account.

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.

Noted (AI summary) Farnham Park GP Practice conducted a Serious Event Audit on 31 May 2022 and identified a clinical psychologist to provide mental health training. Unexpected deaths will be discussed at weekly clinical meetings. NHS England highlights existing educational resources and guidance for GPs and outlines planned future actions including the rollout of the Learn from Patient Safety Events (LFPSE) service and implementation of the Patient Safety Incident Response Framework (PSIRF), and sharing the report with Regional Mortality Boards. NHS Frimley ICB will share the coroner's concerns with GP practices, focusing on documentation of suicide/self-harm risk and mental health assessments. They will also update the local formulary to highlight national guidance on the increased risk of suicidal behavior when starting antidepressants, with a point-of-prescribing alert, to be completed by August 2022. CQC contacted Farnham Park Health Group and received evidence of a significant event analysis and action plan implemented in response to the death, with 7 of 10 actions already completed. They also raised the failure to notify CQC of the death with the provider and will consider further action. The GMC has reviewed the concerns and decided not to investigate further, but will share them with the doctor's responsible officer for discussion during their revalidation. The Department acknowledges the concerns and notes actions taken by other bodies, emphasizing the clinical responsibility of GPs in prescribing decisions and referencing NICE guidelines. It provides general context and reiterates existing guidelines without committing to specific new actions.