West Yorkshire Western

Action Planned (AI summary) The Trust will roll out refresher training for quality governance, patient safety, learning from deaths, and legal staff regarding PSIRF and national guidance on learning from deaths in early 2026. The Trust will also implement a comprehensive Investigation Masterclass Programme.

Action Planned (AI summary) The College of Policing will formally raise the case of Ms. Laskowsky at the next meeting of the NPCC First Aid Forum on 4 December 2025, to ensure that national learning is disseminated and embedded. They will produce national learning summaries and practice notes, update Authorised Professional Practice (APP) and training materials, and engage with force training leads and clinical governance advisors. West Yorkshire Police has posted an intranet briefing reminding staff about the YAS Partner Triage Line, included details in operational briefings, updated training and guidance material, and tasked the Right Care Right Person team with monitoring its usage. First Aid trainers will also remind officers of the YAS Partner Triage Line during annual training. The NPCC has recommended that West Yorkshire Police implement clinical governance arrangements consistent with NPCC guidance and has offered support in implementing this. They confirm that assessment of breathing and responsiveness levels are mandated in Learning Outcome 1.3. of Police First Aid Learning Programme.

Action Planned (AI summary) Calderdale and Huddersfield NHS Foundation Trust will implement a Trust-wide training program for applying and managing hard collars, led by senior clinicians, with sessions scheduled for December 2025 and January 2026. They are also developing a Standard Operating Procedure (SOP) for collar initiation and management to be implemented by the end of January 2026, and care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR).

Action Planned (AI summary) NHS England is advised that the involved GP surgery has taken learnings from Myles’ death, including improved processes for managing patients with learning disabilities and autism and reminding staff of the importance of accurate documentation. NHS England has also been engaging with NHS West Yorkshire Integrated Care Board on the concerns raised. Dalton Surgery has implemented a range of actions including Oliver McGowan mandatory training, Practice Protected Time meetings, and enhanced communication. The practice has developed a detailed action plan with auditable evidence and clear timescales, working with ICB colleagues. CQC has been in contact with Dalton Surgery to establish the full circumstances and request information about their planned actions; they have received an action plan. CQC will use the Oliver McGowan Code of Practice when considering whether providers are meeting regulatory requirements; bespoke upskilling sessions will be run for inspection teams. The CQC has contacted Calderdale and Huddersfield NHS Foundation Trust and will receive information about actions taken to prevent a reoccurrence. The CQC will also use the Oliver McGowan Code of Practice when considering whether providers are meeting training requirements and upskill inspection teams on the mandatory training.

Action Planned (AI summary) The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.

Action Planned (AI summary) The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.

Action Planned (AI summary) The MHRA is working on updating its "Medical devices: information for users and patients" guidance to raise awareness on important considerations prior to purchasing a mobility scooter, with publication expected by June 2025, and will collaborate with relevant stakeholders to disseminate this information. The Department for Transport will liaise with the MHRA to establish whether anything further can be done to prevent such deaths, such as providing information to mobility scooter users about the risks of operating in freewheel mode and warning about the absence of a secondary brake on older models.

Action Planned (AI summary) NHS England shared national guidance on teleradiology, regional colleagues engaged with West Yorkshire ICB, Calderdale and Huddersfield NHS Foundation Trust conducted an After Action Review and REALM teaching session, and discrepancies in reporting were shared with the external provider who will investigate. All reports received are discussed by the Regulation 28 Working Group. The Royal College of Radiologists acknowledged the importance of interpreting radiology in clinical context, emphasized learning from events, and will consider the case theme and signpost a suitable anonymized CT from a different patient in educational material.

Action Planned (AI summary) The RFL will review its Overseas Code of Conduct, with specific reference to player behaviour, this year. Ongoing training will reflect any changes made.

Action Planned (AI summary) The Association of Ambulance Chief Executives will develop new guidance for paramedics on recognising infected surgical wounds at risk of catastrophic bleeding, to be included in existing vascular emergencies guidance. This will be pushed out as a clinical update onto the App following approvals from JRCALC and NASMeD within approximately three months.