Department of Health and Social Care

Noted (AI summary) NHS England has requested that all ICBs put in place integrated crisis text services, with delivery expected across all areas by Spring 2026. Greater Manchester ICB plans to implement commissioned crisis text services as part of crisis transformation, with a phased approach: a contracted service will be launched first, followed by a fully established service. The Department of Health and Social Care acknowledges concerns about the delayed rollout of crisis text support services, highlights existing mental health support initiatives, and notes that NHS England and Greater Manchester ICB are addressing the specific concerns raised.

Noted (AI summary) The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about communication and confusion during medical emergencies in prisons, confirms HM Prison and Probation Service has primacy for command and control, and highlights existing CQC guidance on reducing harm in mental health settings.

Noted (AI summary) The Trust details the role of the GIC as detailed in the service specifications published by NHS England for Gender Identity Services for Adults (Non-Surgical Interventions) and states that it is working with NHS England and other providers to develop innovative ways of reducing the waiting times. NHS England is undertaking a review of adult Gender Dysphoria Clinics, with a report due in Autumn 2025 to inform a new service specification for 2025/26. They are also working to increase capacity in children and young people's gender services.

Noted (AI summary) HMP Guys Marsh has developed its Incentivised Substance Free Living (ISFL) unit, provides comprehensive staff information on illicitly brewed alcohol, and ensures in-cell medication safes are available and fit for purpose. Oxleas NHS Foundation Trust has committed to introducing regular assurance checks for all prisoners in receipt of IP medication. Oxleas NHS Foundation Trust will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh focusing on safe storage and proper disposal of medication. They have published a local In-possession Medication Compliance procedure outlining bi-monthly in-cell compliance checks. HMPPS has developed and disseminated materials focused on illicitly brewed alcohol (IBA), including the Drugs in Prison and Probation (DiPP) guide. The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, and in-cell lockers will be replaced if damaged. The Department acknowledges concerns about medication held in prisoners' possession, but states that national NHS policies for prisoners are the same as those used in the community. They believe existing processes, contractual monitoring, and learning from serious incidents are sufficient, and that national guidance could further complicate the issue.

Noted (AI summary) The Lift and Escalator Industry Association (LEIA) published a safety notice on their website on behalf of Phoenix Lifting Systems regarding lifting platforms with one-touch platform controls and emailed it to all their members. HSE will raise the matter of platform lifts without hold-to-run controls at the national Local Authority Health and Safety Practitioner Forum and in a technical LA bulletin, and will share the circumstances with CQC and the wider healthcare industry. They are also aware that LEIA has raised the concerns with their relevant committees. LEIA published a further safety notice addressing similar hazards in other lifting platforms from other manufacturers and has made proposals for inclusion of recommendations for the revision of BS 5655-11 to cover legacy lifts with similar hazards. DHSC acknowledges the concerns regarding platform lifts in care settings, but states the responsibility lies with the Health and Safety Executive, who have already responded and are monitoring similar incidents. DHSC shares concerns about the incident but states the matters do not fall within their responsibilities; they have written to the HSE to monitor for similar incidents and review if further action is needed.

Noted (AI summary) The Department acknowledges the concerns regarding delayed hospital discharges due to limited social care capacity and describes existing initiatives like the Better Care Fund and care transfer hubs, without committing to new actions. NHS GM will create a GM Falls Prevention Strategy with recommendations for each locality. They will identify the number of GM residents at risk of falls and estimate the cost of falls to health and care services.

Noted (AI summary) The Home Office is researching the availability of the substance in question and supports the DHSC in delivering the Suicide Prevention Strategy for England. Border Force has issued guidance to officers about control actions regarding goods at the border that may assist with suicide. The Department of Health and Social Care acknowledges the concerns regarding the purchase of sodium nitrite but states that the responsibility for these concerns sits within another organization.

Noted (AI summary) The response outlines NICE's role in providing guidance and signposts to other organisations responsible for commissioning services, providing education and training, and funding research. The NIHR is planning a funding opportunity for a development award focussed on evaluating repurposed pharmaceutical inventions and a showcase event for post-acute infection conditions (including ME/CFS and long COVID) research later this year to stimulate further research in this field.

Noted (AI summary) The response details that all Integrated Care Boards are expected to expand local provision by commissioning NHS Talking Therapies services that are integrated into physical health pathways. The practice will also send out the Waltham Forest Talking therapy (IAPT) website details and phone number to all of its patients with chronic diseases, and with stress. The response only contains contact details for Queen Mary University of London's Clinical Effectiveness Group.

Noted (AI summary) NHS England expresses condolences and explains the context of shared decision making and risk assessment, referring to existing national guidance and tools. It states that commenting on the specific clinical decision is outside of NHS England's remit, and refers to the Trust's response regarding handover communications. The Trust has rolled out mandatory consent training and has a focused approach in place to support safe and timely transfers. A daily meeting has been established to identify patients who can be stepped down from ICU care to ward level care. The response acknowledges national guidance from NICE and the British Geriatrics Society and states that Stockport NHS Foundation Trust has taken steps to improve information and training relating to shared decision making and consent. Martha's Rule is being expanded to all acute inpatient sites. Medical examiners have been implemented on a statutory basis.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns about district nurse numbers but states the responsibility lies with local Integrated Care Boards and NHS trusts, while mentioning a forthcoming 10 Year Workforce Plan.

Noted (AI summary) NHS England highlights existing national guidance and safety alerts on anti-ligature measures, and the North London Mental Health Partnership's incident response with recommendations, and will continue to engage with local teams for updates. The organisation also notes that all reports received are discussed by the Regulation 28 Working Group. The Department acknowledges the concerns and references existing guidance from the Care Quality Commission and NHS England on anti-ligature measures, as well as ongoing work via NHS England's mental health inpatient quality transformation programme and the national Suicide Prevention Strategy.

Noted (AI summary) The North East and North Cumbria Integrated Care Board acknowledges the concerns, noting the existing systems for patient record sharing via the Great North Care Record and the responsibility of medical professionals within multidisciplinary teams. They also refer to NHS England guidance on outpatient services. Moorbridge School has conducted a thorough review of their practices related to information sharing and safeguarding and will revisit and reinforce staff understanding of these policies through annual refresher training. 49 Marine Avenue GP Surgery acknowledges shortcomings and will strengthen communication with secondary care, improve multidisciplinary communication, and review safeguarding procedures. They will also implement new guidelines for monitoring, supporting families, and provide staff training in eating disorder management. The Trust has implemented a restructure within the Dietetics Service, introduced mandatory training for staff on safeguarding children, and will discuss information sharing between primary and secondary healthcare at the NENC GP Provider interface group by October 2025. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue and aim to have a Single Patient Record processing information by 2028.