NHS England

Action Planned (AI summary) NHS England shared national guidance on teleradiology, regional colleagues engaged with West Yorkshire ICB, Calderdale and Huddersfield NHS Foundation Trust conducted an After Action Review and REALM teaching session, and discrepancies in reporting were shared with the external provider who will investigate. All reports received are discussed by the Regulation 28 Working Group. The Royal College of Radiologists acknowledged the importance of interpreting radiology in clinical context, emphasized learning from events, and will consider the case theme and signpost a suitable anonymized CT from a different patient in educational material.

Action Planned (AI summary) A LeDeR review is in progress to look at the care delivered, and NHS England is sharing learnings from PFD reports nationally via a working group. The response provides context and explanation but does not describe completed actions. The CQC has received and accepted an action plan from the Hull University Teaching Hospitals NHS Trust following Mr. Lodge's death, and is monitoring progress through regular engagement and a monthly Quality Improvement Group. They have also requested evidence of action taken following the death, and will check compliance with regulations during the next inspection. The Trust outlines actions taken since January 2022, including the creation of NHS Humber Health Partnership and various groups sharing knowledge to improve patient safety. They have implemented a new NEWS2 escalation process, mandatory training, and a frailty pathway, and are actively participating in the Learning Disabilities Mortality Review programme.

Action Planned (AI summary) NHS England acknowledges the long waits for ADHD services and describes a national programme to improve access, including exploring digital options for diagnosis and support, and moving to a needs-based approach. They have also developed guidance for systems to manage medication shortages. The RPS published a report on medicines shortages in Nov 2024 and will consider how to raise awareness of these issues through future communications and engagement and with professional bodies for pharmacy.

Action Planned (AI summary) The government has set delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS, including improving A&E and ambulance wait times. In Spring 2025, the Government will publish its 10-Year Health Plan which will set out radical reforms for the NHS. NHS England is working to improve Category 2 ambulance response times and urgent and emergency care services by growing the workforce, improving hospital flow, reducing handover delays, speeding up discharges, and expanding community services, and has set targets for 2024/25. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions.

Action Planned (AI summary) NHS England will continue to support provider Trusts to deliver appropriate training and support to staff to deliver reasonable adjustments and accessible communication for patients. NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. The DHSC is rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism and NHS England is rolling out further training for staff working in mental health services to upskill staff in supporting autistic people in contact with those services.

Action Planned (AI summary) The Department is reviewing information on the Better Health - Start for Life website regarding the safe use of baby carriers to ensure it is sufficiently prominent. They are also considering ways to supplement the content and engaging with key stakeholders to ensure the messaging is correct regarding the use of baby carriers and breastfeeding. NHS England acknowledges the need for clearer guidance on safe sling use and will work to improve the visibility and linking of existing resources on NHS.UK. They have referred the issue to NICE for consideration and passed details to UNICEF-UK. Several charities have agreed to advise parents that hands-free breastfeeding using slings and carriers is unsafe and should not be attempted. The Lullaby Trust is funding research and will convene a roundtable to agree simpler, consistent messaging for parents and stakeholders on safe sling and carrier use. OPSS is aware that Merton Council Trading Standards are investigating the specific product involved in the death, focusing on its compliance with safety standards. OPSS will also bring any updates to Government or NHS advice regarding infant safety in slings to the attention of trade associations and review the designation of the voluntary standard.

Action Planned (AI summary) NHS England is prioritizing improvements to hospital discharge, coordination of community-based services, length of stay for admitted patients, and reducing delays. Regional colleagues have engaged with Humber Health Partnership to address ambulance handover times, and all reports received are discussed by the Regulation 28 Working Group to share learnings. The Humber Health Partnership implemented the 045 Handover Plan at Hull Royal Infirmary in December 2023, using a phased approach to reduce ambulance handover times. They have also implemented a Temporary Escalation Space (TES) and Boarding Standard Operating Procedure to improve patient flow and increase bed availability. The ERSAB and ASCH are collaborating with Hull City Council to review and renew the VARM procedure, to be renamed Multi Agency Risk Management (MARM) meeting procedure, expected to be finalised in early 2025. The service will consider making MARM training mandatory for practitioners.

Action Planned (AI summary) NHS England acknowledges concerns and will work with the MHRA to establish a communication Memorandum of Understanding to share learning from serious incidents related to aseptic medicines preparation/manufacture. They also note that all reports received are discussed by the Regulation 28 Working Group to share learnings across the NHS. CQC will review oversight of independent sector providers not subject to iQAAPS audits during 2025-26. It will also use the iQAAPS dashboard to discuss organization-specific risks with NHS trusts during 2025-26. NHS England has strengthened guidance on aseptic preparation of medicines and auditing and introduced strengthened oversight and external quality audits via the iQAAPS web-based quality reporting system. NHS England, MHRA and CQC will implement a 2-way information sharing agreement at organisational level to share learning of serious incidents related to aseptic medicines by end of June 2025. DHSC will meet with CQC, NHS England and MHRA to ensure that the actions of each organisation to address concerns are complementary, coordinated and completed. The MHRA will publish an update to the sector detailing issues raised by this case and our intentions to address the concerns (by the end of March 2025), agree and implement a memorandum of Understanding (MoU) with NHSE for routine updates and also the dissemination of ad hoc learnings from incidents (by end of June 2025). The MHRA will inform devolved governments of this requirement to improve information exchange as soon as practical and agree an approach in line with that for the NHSE MoU (by end of September 2025).

Action Planned (AI summary) NHS England is working on interoperable medicine standards (IMS) to improve medication information sharing, with projects expected to roll out over the next 2-5 years. They also highlight existing screening processes in prisons.

Action Planned (AI summary) NHS England plans to revise Detention Services Order 09/2016, Rule 35 assessments towards a multidisciplinary approach to safeguarding and vulnerability management in Immigration Removal Centres, and will jointly develop a stakeholder engagement session with the Home Office to share the revised requirements with IRC providers and operators. The Home Office is developing an interim update to its Rule 35 guidance, strengthening monitoring in detention, and implementing a 'Prevention of future deaths in immigration detention strategy'. Progress will be reported through the MBDC governance structures. Mitie Care and Custody has implemented a revised Standard Operating Procedure to prevent "closed visits" and has introduced a website translation and accessibility service called 'Recite' across its immigration removal centres.