West Yorkshire (Eastern)

Noted (AI summary) Wakefield Council is undertaking physical works, including building robust barriers and installing a safe viewing platform at Kirkthorpe Weir, expected to be completed in mid-July 2021. They are also linking still water body health and safety policies to flowing water areas. Yorkshire Hydropower Limited has undertaken a detailed review of trespasser routes and plans to improve signage, install additional CCTV cameras with remote monitoring, and engage with the local community and police to deter further trespass. Foresight Group states it is the investment advisor to Yorkshire Hydropower Limited (YHL), and does not exercise control over YHL's affairs, so YHL are taking steps to ensure there is no repetition of this tragic accident. Foresight endorses the proposed security measures outlined by YHL, which include additional fencing, warning signs, enhanced CCTV, improved PA system, barriers, covering channels, ongoing liaison with emergency services, and daily manned security presence during summer months. The Canal & River Trust's national Education team produced a Schools Water Safety Awareness Communication and a water safety video aimed at children aged 5-11 years which focuses on the Trust's ‘Stay Away From the Edge’ campaign.

Noted (AI summary) The Trust is providing additional 'fit testing' for PPE outside of usual provision and plans to standardise 'bank notes' on shifts in high risk areas specifying the need for fit testing, with audits to check implementation. They have also advised high risk staff to contact Reed to check the status of wards, and carry their risk assessments. Reed Specialist Recruitment states they have complied with their contractual obligations and notified relevant authorities (EAS, CCS, CQC). They suggest the report be re-addressed to ID Medical, the direct supplier of the worker in question. The Employment Agency Standards (EAS) Inspectorate explains its role in enforcing regulations for employment agencies, outlining the checks and authorisations required to ensure the suitability of work-seekers, including healthcare workers.

Noted (AI summary) BAM Nuttall was not involved in the design of the weir installation but will share the Coroner’s Report to Prevent Future Deaths with any designers of weirs in future projects where BAM Nuttall is acting as Principal Contractor. They are committed to the ongoing training of its workforce and the development of ever safer systems of work. BMM JV was not involved in construction or site operations or in the weir design, but will ensure the Report is shared with other designers in future weir projects.

Noted (AI summary) The Department of Health and Social Care is awaiting research on the Brazilian Butt Lift procedure. They will be updating existing guidance about surgical fat transfer procedures to reference the Brazilian Butt Lift by March 2020. The operator of Elite Aftercare confirms the business has ceased trading since the conclusion of the inquest. The GMC acknowledges the concerns and shares information about their role in regulating doctors and setting standards. They note the BAAPS moratorium and discuss credentialing for cosmetic surgery, but state that they do not have the legal authority to make any postgraduate training mandatory.

Noted (AI summary) Whitelocks Development Ltd has purchased warning triangles for HGVs, instructed drivers on emergency service contact, instructed drivers to clean light lenses and are considering fitting auxiliary warning lights, with completion of these actions planned for end of November 2019. The Office of the Traffic Commissioner explains the Traffic Commissioners' role and refers the coroner to the Department for Transport regarding legislation and the DVSA regarding driver training. DAF Trucks states that the vehicle was originally supplied with a safety kit including warning triangles, and that a bulb monitoring system was in place. They deem no action is required from them, as the lighting system was subsequently altered by another organisation. The RHA will raise awareness of equipment shortages and driver training issues through member emails, a magazine article, and at member events.

Noted (AI summary) The University of Birmingham offers condolences and provides background information on its commitment to clinical trials, then addresses specific questions raised by the coroner regarding the medical details of the case, without outlining any actions to be taken.

Noted (AI summary) The Trust acknowledges the coroner's concerns regarding radiology reporting turnaround times but states that there are no national standards. The Trust prioritizes resources to acute, clinically urgent, and cancer pathways, and routine outpatient work may wait longer.

Noted (AI summary) The Trust describes its processes for safe discharge of elderly patients, including defining frailty, use of ACE units, care home liaison, and gathering patient feedback, but doesn't outline specific changes made in response to the report.

Noted (AI summary) HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained staff sufficient based on a first aid risk assessment, referring to PSI 29/2015.