CQC

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 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.

Noted (AI summary) CQC commenced an inspection of Downshaw Lodge on 16 October 2024 to review matters in relation to ongoing risk and to assess documentation; findings will be published on the CQC website. An initial assessment concluded there was no evidence of a registered provider level failure to meet the threshold at which criminal enforcement would be considered. No information provided.

Noted (AI summary) DHSC reports that Tameside and Glossop Integrated Care NHS Foundation Trust completed work on re-developing its urgent care and emergency departments in July 2024, including front-door streaming, an Urgent Care Transformation Programme, and a review of the emergency department to avoid hospital admissions for those patients living with frailty; The Lakes Care Centre is no longer registered for nursing, and is under new management. The CQC acknowledges concerns about care at The Lakes Care Centre. The provider has ceased to deliver the regulated activity of 'Treatment for Disease, Disorder or Injury' and the CQC will seek to register a suitable candidate for the registered manager role. Response consists of the text A1, A2, and A3. Unable to classify without further content.

Noted (AI summary) Westmorland Court Care Home states that a number of improvements have taken place since the death, including implementing a Quality Improvement Plan with the ICB and Westmorland and Furness Council. Staff training has been refreshed and updated, and reflective accounts of the incident were completed. The NMC acknowledges the concerns and states they have passed information to their Employer Link Service and New Referrals team to make enquiries and will investigate concerns within their remit. They have also referred the case to the Public Support Service to reach out to the family. The CQC acknowledges the concerns raised and outlines actions taken following previous notifications, including a targeted inspection. They state that mandating defibrillators in care homes falls outside their remit but expect providers to have appropriate policies for resuscitation.

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) Outlook Care has implemented an action plan including external feedback, stakeholder inclusion in reviews, and collaborative working with LBWF. They've revised their Missing Person policy, provided staff training, and conducted spot checks on 1:1 support, issuing guidance on maintaining a 'line of sight'. Future actions include business continuity tests, audits of risk management, and revised induction formats. The CQC reviewed information on Waterside Lodge Recovery Centre and requested a copy of Outlook Care's response to the coroner, noting changes across their remaining nine locations including review of missing person policy, training for staff, additional risk assessments and spot checks on community visits, and will request and review evidence of completion of these actions. The London Borough of Waltham Forest explains its processes for monitoring commissioned supported living services and managing parks/open spaces. They state that the support worker was not employed or commissioned by them. They outline referral pathways for vulnerable adults, rough sleeping monitoring, and vegetation management but do not commit to specific changes. The Metropolitan Police state that they have been unable to identify any other deaths in the area that would suggest any specific or ongoing risk to public safety, or significant criminal activity. They confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping and have increased engagement with local residents to encourage reporting of rough sleeping.

Noted (AI summary) The Integrated Care Partnership states that District Nurses share advice via a Communication Book and that the Trust has provided a timeline of communication with the care home. They describe the process for Tissue Viability Nurses to review and provide advice, including the use of wound photography and communication with the nursing service. CQC will follow up with Stockport NHS Foundation Trust at future engagement meetings to ensure that appropriate reflection has taken place and learning from this incident disseminated. CQC are continually monitoring the service and liaising with the Integrated Care Board to review any ongoing risks and feedback.

Noted (AI summary) Skills for Care recommends that every frontline care worker within a CQC regulated service should receive First Aid training, including basic life support as part of their initial induction to the sector, and ensure these skills are regularly refreshed. They highlight existing guidance and initiatives, but note that they cannot mandate training. Peabody has improved its training program for care workers in supported living environments, now requiring certified First Aid and Basic Life Support training before solo work. Existing care workers will also complete the new course within one year and the organisation has launched an Ofsted-registered Academy. CQC acknowledges the regulation regarding staffing qualifications and training and highlights that Peabody has revised protocols to ensure no support worker lone works without enhanced training in emergency first aid and basic life support, and is ensuring appropriately trained personnel on every shift. CQC will be considering the case under its framework for health and safety incidents.

Noted (AI summary) West Midlands Ambulance Service acknowledged the ECG was abnormal and that policy wasn't followed; clinicians received a case review, participated in a Serious Incident process, completed reflective practice, and are scheduled for additional ECG/ACS training. Additional actions include updating policies and providing additional equipment/training to improve chest pain management and ECG interpretation. The Health and Care Professions Council acknowledges the concern but states that the individual in question is not registered with them, so the concerns do not fall within their remit for further investigation, but the individual's name has been added to a watchlist. The Health Services Safety Investigations Body is undertaking exploratory work regarding paramedic interpretation of ECGs in the community and will consider the scope for a formal investigation by the end of January 2024. The University of Wolverhampton will present case evidence to students, incorporate ECG interpretation into Objective Structured Clinical Examinations, liaise with coronary care units for anonymised ECG readings, add an ECG interpretation workbook to the virtual learning environment, and organise continuing professional development ECG masterclasses. The CQC has reviewed WMAS's actions following the death and found no evidence of provider-level failings, although they identified concerns regarding the timeliness of addressing the training needs of staff involved. The training needs of one staff member have been addressed, and the second staff member's training will be met upon their return to work.