NHS England

Action Planned (AI summary) NHS England published principles for supporting improved quality of care in Temporary Escalation Spaces (TES) in September 2024. In June 2025 they published the Urgent and Emergency Care (UEC) Plan for 2025/26. Since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. The Department for Health and Social Care outlines the Urgent and Emergency Care Plan for 2025/26, including investments in same-day and urgent care services, increasing urgent care in community settings, and introducing new clinical operational standards. They also mention plans to publish data on corridor care to drive improvement.

Action Planned (AI summary) NHS England states that documenting communication between community midwives and hospital staff is standard via Electronic Patient Records; SPR will be rolled out in maternity care first. Concerns have been shared with maternity and neonatal units across the East of England region, and they have been reminded to record discussions on electronic records where available; all reports are discussed by the Regulation 28 Working Group. RCPCH acknowledges concerns about documenting calls from midwives to hospital teams and supports the use of the NHS number as a single unique identifier. They are actively supporting the rollout of Martha’s Rule, an inpatient safety initiative, and learnings from the pilot could in future be applied in the community setting.

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) NHS England is developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems, to ensure all required information is available to staff. It highlights existing systems, including the National Care Records Service, and discusses reports received by the Regulation 28 Working Group.

Action Planned (AI summary) NHS England's South West region is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, expected to be functional from 1 November 2025, supported by clinical improvement projects including training, pre-hospital video triage, and improved pathways. NHS England's South West region is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, expected to be functional from 1 November 2025, supported by clinical improvement projects including training, pre-hospital video triage, and improved pathways.

Action Planned (AI summary) Lancashire Teaching Hospitals has updated its stakeholder communications policy to reflect the current operational hours of the Mechanical Thrombectomy service and issued a follow-up communication for assurance through the Chief Operating Officers network. Direct contact has been made with Salford Royal Hospital to seek potential regional support options. NHS England is working with Lancashire & South Cumbria ICB to support Comprehensive Stroke Centres (CSCs) to deliver a 24/7 thrombectomy service. They have requested an urgent review of mechanical thrombectomy provision within the North West and expect a fully operational 24/7 service at the Preston site by October 2025. Lancashire Teaching Hospitals has updated the stakeholder communications policy to reflect the current operational hours of the Mechanical Thrombectomy service and issued communications via Chief Operating Officers. The Northern Care Alliance NHS Foundation Trust is participating in discussions with NHS England, Lancashire Teaching Hospitals and the Walton Centre to explore options for providing aid overnight, with follow-up meetings planned to progress plans and clarify timelines. A meeting between the Trust, NHSE and Lancashire Teaching Hospitals took place on 15 July 2025 to discuss this, where possible options for providing aid overnight were explored. Royal Lancaster Infirmary shared learning from the case and inquest feedback with the team, discussed it at a governance meeting, and is ensuring wider distribution of Royal Preston Hospital thrombectomy service hours, also added to handover sheets and nursing handovers.

Action Planned (AI summary) NHS England will discuss details of the case with the NHS England AMPDS clinical coding sub-group, in collaboration with PDC, to determine if there are opportunities to improve the assessment and differentiation of abdominal pain presentations within the AMPDS triage system. NHS England has additionally shared the Coroner’s concerns with PDC.