Teesside and Hartlepool

Noted (AI summary) The BSG acknowledges the concerns regarding colonoscopies for patients over 80, stating that decisions should be individualised, balancing risks and benefits.

Noted (AI summary) Redcar and Cleveland Borough Council will recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the concerns identified through Mr Bradley’s inquest. They reiterate the use of the Crisis Assessment Suite at Roseberry Park as the appropriate place of safety. Stockton on Tees Council will bring TEWV's Section 136 policy to the Mental Health Legislation Operational Group to consider further education for Cleveland Police. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care. Middlesbrough Council will ensure their mental health service receives refreshed communication regarding section 136 guidance, and the circumstances relating to the Regulation 28 report. This will be flagged within the Multi-Agency Mental Health Legislation Operational Group to determine the need for further awareness and training among wider partners. Hartlepool Council will give consideration to further education and awareness raising within Cleveland Police regarding the use of Section 136 powers. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the inquest's concerns. The ICB acknowledges the concerns regarding mental health safeguarding for intoxicated individuals, explains existing crisis services, and states they have no plans for a specific holding facility. They note that the crisis team was not contacted in this specific case, so they can't comment on the potential outcome. Tees, Esk and Wear Valley NHS shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025 to ensure awareness of the Report and best practice. This report has also been shared with Crisis Teams. The Department of Health and Social Care liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding directly. They also mentioned Cleveland Police began to implement the Right Care Right Person approach in 2024, and committed £26 million in capital investment to support people in mental health crisis.

Noted (AI summary) NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National Primary Care Team will consider GP awareness of alerting ambulance services to specific conditions; the ICB will take the circumstances surrounding Margaret’s death to their GP learning sessions and consider a system-wide safety alert. AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient addresses. NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, and accepting care plans and flags from providers until an automated solution is available. They have also established an ICB-wide group to improve flagging challenges.

Noted (AI summary) NEAS will undertake a review of the triage process and NHS Pathways questions, focusing on call re-categorisation. They are finalising a business case for commissioners to consider, which would support the introduction of a Critical Incident Hub to increase the number of dispatch officers. The Department acknowledges the concerns regarding the NHS Pathways system and the pressures on ambulance services. It highlights improvements in ambulance response times and ongoing efforts to boost ambulance capacity, but describes no specific changes to policy or procedures related to the concerns raised.

Noted (AI summary) The North East Ambulance Service details their procedures for checking doors and alternative transport options, noting that welfare calls are prioritized for patients who are alone.

Noted (AI summary) The Highways Agency has extended a route safety study to consider whether a bridge at Elwick could facilitate closure of central reserve gaps, including the Dalton Piercy junction. The study is due to report in August 2015. Hartlepool Borough Council clarifies that the relevant stretch of road falls under the jurisdiction of Highways England, but they are in dialogue with Highways England and will assist as required.

Noted (AI summary) BOC states they followed all procedures and contractual obligations, and all equipment was in working order. They see no reason to take further action but will monitor procedures.