CQC

Noted (AI summary) • The GP practice has taken actions to monitor potential overuse of inhalers and ensure patients and families are aware of the risks.

Noted (AI summary) NHS England refers to updated guidance regarding risk of harm to self, and states that secure access to fire escapes should be embedded within providers’ risk assessments. They state that they cannot comment further on the specific local risk assessment and direct the Coroner to the Birmingham and Solihull Integrated Care Service. The trust has updated the Environmental Risk Assessment to include the Fire Escape, installing metal fence panels and an eight-foot-high gate on the ground floor, as well as metal panels at the top of the fire escape platform. The ICB will share learning from this incident with all local mental health and rehabilitation providers by 17th December 2025. CQC acknowledges the concerns and notes that the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 apply to registered providers. They signpost to information regarding fire safety and environmental safety on their website but state they are not aware of specific guidelines regarding fire escapes in rehabilitation settings.

Noted (AI summary) NHS England highlights existing functionalities such as the National Care Records Service (NCRS) and the SystmOne out-of-hours system that enable access to patient's Summary Care Record (SCR). They also note that Holderness Health migrated from EMIS to TPP SystmOne with GP Connect enabled to improve interoperability. Holderness Health confirms it migrated to TPP SystmOne with GP Connect enabled for interoperability, but the patient's surgery was 14 years ago and not considered a significant active problem. The CQC contacted the GP practice and Out of Hours provider to establish circumstances and intended actions. They state they ensure that they look closely at how providers deal with incoming correspondence, coding, and sharing of information during inspections, and were satisfied with the significant event analysis undertaken. The RCGP will highlight the case to their health informatics group to influence discussions with NHS England and will also highlight the concerns to The Professional Record Standards Body (PRSB).

Noted (AI summary) NHS England is developing a Reasonable Adjustment Digital Flag to record information about patients, including if they are autistic or have a learning disability, and their reasonable adjustment needs. The RCEM highlights existing resources such as the Learning Disabilities Toolkit and involvement in the development of the ED version of the national paediatric early warning system (nPEWS). They feel unable to comment on inpatient care and state provision of learning disability nurses is outside their remit. CQC acknowledges the concerns but states that commenting on the specific guidance is outside of their regulatory scope. They are reviewing the case in line with their incident guidelines. The Trust is developing a Learning Disability Admission Checklist to provide prompts for staff in Emergency Departments and establish a system to record reasonable adjustments, planned for Quarter 3, 2025. RCPCH's revised Facing the Future: Emergency Care Standards will be published in Autumn 2025 and shared with relevant professionals, and will include a standard on EDs having a lead professional for CYP with complex needs and access to advice from a Learning Disability Liaison Nurse. The Department highlights the upcoming 10-Year Health Plan which will improve awareness of learning disability and autism within the health and social care system. It also references Martha's Rule which gives patients and their families the right to initiate a rapid review of their case.

Noted (AI summary) The CQC acknowledges the concerns, noting that the care home in question is now dormant and outlining CQC's role and inspection methodology. They state that the Secretary of State for Health and Social Care is better placed to address concerns about pressures on the ED. Tameside Metropolitan Borough Council has revised its Multi Agency Concern (MAC) process to ensure providers notify families of concerns and has increased the number of quality monitoring officers to conduct more robust contract monitoring. The Department of Health and Social Care highlights the opening of an additional ward at Tameside General Hospital in November 2024 to provide additional capacity and support patient flow, as well as the £9 billion committed to the Better Care Fund to tackle delayed discharges.

Noted (AI summary) Procter & Gamble expresses condolences, states its products comply with regulations and are safe when used as directed, and maintains a post-market surveillance system; they are not proposing changes to the product or packaging but will continue to monitor adverse events and respect the coroner's perspective about risk assessments in care homes. The CQC will feature the incident on its Learning from safety incidents webpage to raise awareness and share learning with providers, advising providers to consider denture adhesive gel in risk assessments and care planning, referencing HSE's COSHH Risk Assessment and CQC's Regulation 12.

Noted (AI summary) NHS England acknowledges concerns about public understanding of Physician Associates (PAs). It highlights the Leng Review of PA and AA professions, the establishment of PA title by law, and existing guidance on PA deployment. The RCEM issued new guidance moving PAs to Tier 2 on the ED rota. The Trust implemented the changes immediately, and PAs at the Trust are also now trained to state that they are not a doctor. The RCEM issued a position statement in June 2024 regarding Physician Associates which included supervised practice, public awareness, undifferentiated patients, and regulation. RCEM has worked with the national emergency laparotomy audit project (NELA) for several years to improve the care of patients who require an emergency laparotomy (abdominal operation). The CQC acknowledges the coroner's concerns regarding Physician Associates and rapid sequence induction but states that some points are outside of their regulatory scope. They will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of their ongoing monitoring and engagement with them. DHSC acknowledges concerns regarding Physician Associates, rapid sequence induction, and guidelines. They highlight that healthcare professionals must practice within their competence. NHSE has issued guidance on the deployment of PAs and AAs in the NHS and NHS Employers has also published guidance for employers. The Association of Anaesthetists and RCOA Difficult Airways Society address concerns raised and reference existing guidelines; they state that the topic of rapid sequence induction (RSI) is controversial and best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. The GMC highlights its new powers to regulate PAs and AAs and states that it is developing website materials, due to be published in Spring, to support doctors who are supervising PAs. Surrey & Sussex Healthcare NHS Trust acknowledges concerns regarding public understanding of Physician Associates, rapid sequence induction, and the use of cricoid pressure. It states PAs wear different coloured scrubs, and are trained to introduce themselves as PAs. They communicated the importance of cricoid pressure to the anaesthetic team and trainees, and that modified TIVA technique is used with a predetermined dose of propofol and muscle relaxant. The RCP acknowledges concerns about the safe deployment of PAs and notes that the Faculty of Physician Associates was dissolved on 31 December 2024. It highlights concerns regarding regulation, scope of practice and supervision and states they have now delivered the results of a working group on PA and have submitted their findings to the Leng review alongside a submission from their resident doctors.

Noted (AI summary) NHS England is committed to improving Electronic Patient Records (EPRs) across all NHS Trusts and has provided funding to ensure all NHS Trusts have an EPR implemented. An updated MHLT policy outlines the required documentation the MHLT will provide to acute trusts. CQC acknowledges the concerns raised, and states how they will be reviewed via their internal Specific Incidents Guidance (SIG) and that they will continue to monitor the trusts in line with their internal processes and methodology.

Noted (AI summary) NHS England acknowledges concerns and outlines existing oversight mechanisms, offering support to connect TCT's clinical team to specialists within the NHS and supporting TCT in connecting within the local integrated care system to improve flow to clinical appointments. CQC states that The Children's Trust (TCT) have strengthened their frequency of monitoring policy and increased their audits of the implementation of this policy; have a Frequency of Monitoring Policy in place since July 2022 which continues to be reviewed and updated. CQC have seen evidence of a strengthened learning culture at TCT through inspection and routine engagement conversations. The DHSC acknowledges the concerns raised in the report and states that they have sought assurances from the CQC and NHS England that responses are being prepared to address concerns respective to each organisation. They highlight ongoing monitoring by the CQC and clarify commissioning responsibilities. The Children's Trust has revised its Frequency of Monitoring Policy, enhanced clinical governance frameworks, and strengthened integration with NHS services following the death of Mia Gauci-Lamport.

Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.

Noted (AI summary) The DHSC acknowledges concerns about care shortages, communication gaps, and wound care access. A change in practice resulting from this case has been that pre-admission assessments are now always undertaken. The CQC acknowledges the concerns, states that Hilltop Hall does not have a registered manager in post and that they will write to the registered provider to seek clarification on when they propose to register a manager and may take action if dissatisfied with the actions taken. The registered provider has reflected on the circumstances of this case and identified lessons learned to mitigate the risk of such occurrences and improve the service they provide. Greater Manchester Integrated Care provides background information about the patient's attendances at Trafford Urgent Care Centre and subsequent community nursing care, without outlining specific actions.