NHS England

Noted (AI summary) NHS England discusses reports to prevent future deaths in a working group and escalates risks nationally through committees, referencing the Three year delivery plan for maternity and neonatal services and the Maternity and Neonatal Safety Improvement Programme. NHS Lancashire and South Cumbria ICB outlines measures in place to monitor compliance, including the reporting and escalation process and also that the North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The Trust has reviewed practices, policies, and procedures, implemented mandatory training on candour, revised investigation processes, increased bereavement support, and implemented measures for consultant oversight. They also have enhanced incident review and executive oversight processes, including learning response leads. NHS Lancashire and South Cumbria ICB clarifies the independence and current availability of its Maternity and Neonatal Independent Senior Advocate role, noting it's under national evaluation and currently unable to accept new referrals.

Noted (AI summary) NHS England acknowledges concerns, points to ICB responsibility for local care provision, highlights national guidance, and explains the purpose of the Special Allocation Scheme. NHS Devon highlights improvements to the Special Allocation Scheme including reviewing the process the practice has followed, and a modification to the SOP requiring written confirmation from Practices that they considered all possible alternative approaches prior to placement, enacted in May 2025. Devon Partnership Trust highlights the planned opening of The Brook, a ten-bedded inpatient unit for adults with learning disabilities and/or autism, and the commissioning of a Learning Disability/Autism Outreach team, both expected in summer 2025.

Noted (AI summary) NHS England notes the local Trust has completed immediate deployment of RCEM guidelines for procedural sedation in the ED and is reviewing the safe sedation policy; weekly discharge planning meetings are held, and informatics is reviewing discharge letters. The DHSC points to existing 'Hospital discharge and community support guidance' and states that NHS England will ensure the guidance is followed, with officials working to prevent similar situations in the future.

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 about the death of Ella Murray, focusing on areas within its national policy remit, and will consider the ICB's response. It highlights the role of Integrated Care Systems and Provider Collaboratives and notes that the NHS England South East regional safeguarding team will have oversight of the ICB's actions. Key learnings will be shared across the NHS through the Regulation 28 Working Group. The Department of Health and Social Care expresses condolences and refers the coroner to NHS England, Kent and Medway Integrated Care Board, and the Department for Education for specific responses. The response outlines existing safeguarding duties, information sharing frameworks, and suicide prevention strategies, plus investment in mental health services.

Noted (AI summary) NHS England has introduced national monitoring of patients waiting over 72 hours in emergency departments for mental health placements and action cards for trusts to reduce time spent in emergency departments. The South East region is developing a Standard Operating Procedure for managing mental health presentations with A&E departments. NHS Sussex acknowledges the concerns regarding lack of inpatient beds and long wait times in A&E, explaining their role in commissioning services and the demand for mental health services. They describe the number of commissioned beds and gender-specific accommodations.

Noted (AI summary) NHS England states that the contract with NRS Healthcare was managed by the London Community Equipment Consortium, to whom the Coroner may wish to refer concerns. They note that concerns about NRS Healthcare's services were escalated to the London Regional Quality Group. NRS Healthcare is providing additional training to customer service operatives, enhancing working arrangements, reorganizing Community Equipment Technician teams, and improving communication processes. The London Community Equipment Consortium completed an equipment review of lateral turning systems, and the TOTO should be phased out.