NHS England

Noted (AI summary) NHS England acknowledges the concerns and will review UKHSA's response, while highlighting existing IPC guidance aligning with 'The Green Book' and planned discussions by the Regulation 28 Working Group. The UKHSA expresses condolences and explains its role in iGAS notification and investigation. It states that it has no plans to amend the 'Green Book' guidance regarding alcohol wipes prior to vaccinations, as the matter falls outside of its remit. Browney House Surgery will use the case as a learning exercise, staff will attend Infection Prevention and Control courses, enroll into an Injection Administration Training course and follow local and national guidance. DHSC has determined that UKHSA is better positioned to address the issues raised in the report, as responsibility for guidance on immunization procedures lies with them.

Noted (AI summary) NHS England has asked ambulance trusts to confirm compliance with NHSE guidance and has escalated the issue with the 25-C codes to the International Academies for Emergency Dispatch for rapid resolution. AACE states that the primary ownership of the concerns regarding 999 call categorisation lies with NHS England and that they have liaised with NHS England to ensure the matters of concern are being considered.

Noted (AI summary) NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group.

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 concerns about periacetabular osteotomy (PAO) procedures and states that it is a specialist procedure that should be undertaken only by clinicians with the requisite training and experience. They defer further comment on the specific concerns to Barts Health NHS Trust and suggest the coroner refer to the Royal College of Surgeons or the British Orthopaedic Association for further information.

Noted (AI summary) NHS England is awaiting DHSC's final ME/CFS Delivery Plan and is developing e-learning modules for healthcare professionals. They have engaged with NICE regarding guidance on ME/CFS and nutrition support, and regional colleagues are working with Royal Devon University Healthcare NHS Foundation Trust to develop formal pathways for acute admission and emergency admission for patients with ME/CFS. NICE will review evidence on dietary management for severe ME/CFS published since the 2021 guidelines and consider amendments to emphasize the need for appropriate nutritional support. It will also work with the Royal Devon University Healthcare NHS Foundation Trust to identify examples of good practice and determine if any updates to the section on fatigue are possible in NICE Clinical Knowledge Summaries. The MSC highlights that it is not a regulator but shares information about how ME/CFS is taught and assessed in medical schools, noting the GMC's new national licensing exam and examples of curriculum content. It has also shared the NHS England e-learning package on ME with medical schools. DHSC will reconvene the ME/CFS Task and Finish Group to develop a final delivery plan by the end of March 2025, focusing on research, attitudes, and education. NHS England is establishing a working group to determine additional support for commissioners, and NICE will review evidence on dietary management and strategies for severe ME/CFS and amend guidance. The MRC has invested £3.6m since 2019 in ME/CFS research in partnership with the NIHR, including co-funding the DecodeME study, and continues to engage with researchers and patient representatives to catalyse biomedical research in this area.

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) NHS England states that Stockport NHS Foundation Trust plans additional weekend lists to reduce Stress Echocardiogram waiting times and hopes to achieve a 6-week standard by 31st January 2025. NHS England is not developing an MR angiogram service at this stage. Stockport NHS Foundation Trust plans an additional 20 weekend lists for Stress Echo to clear the backlog by 31st January 2025, aiming to achieve a 6-week standard for all patients. The Trust is also reviewing CT Coronary Angiogram service provision as part of its service development programme for next year. DHSC acknowledges the concerns but states that the procurement of diagnostic equipment falls under the responsibility of the trust and NHS England, who are better positioned to respond.

Noted (AI summary) NICE acknowledges the concerns raised but does not consider any actions from NICE would address the issues. East Kent Hospitals is reinforcing the Acute Abdominal Pain Pathway (AAPP) through monthly teaching sessions and case discussions. The AAPP document includes updated patient risk assessment, and the Hospital Discharge and Criteria to Reside Policy was updated to include a checklist for self-discharge. NHS England states that the concerns are local issues for the Trust to address, but that regional colleagues are engaging with the ICB and NHS England will review the Trust's response; also describes national work on PFD reports.

Noted (AI summary) NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care. The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level.

Noted (AI summary) NHS England is undertaking national efforts to educate the public on appropriate use of 999, including national public education campaigns signposting to various services and resources. They are also working to improve ambulance capacity, hospital flow, and reduce handover delays. The Department acknowledges the concerns regarding ambulance service pressures and handover delays, noting NHS England is addressing these regionally and nationally. The government is committed to safe operational waiting times, an independent investigation has reported on NHS performance, and a 10-year plan to reform the NHS is in development.

Noted (AI summary) NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports.

Noted (AI summary) NHS England outlines national standards for neonatal critical care units, references BAPM standards, notes NHS Trusts exercise their own policies for on-call response times, and states that University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board have been engaged on the concerns raised in the report. The British Association of Perinatal Medicine (BAPM) will send out a safety alert to its members and stakeholders drawing attention to recommendations about consultant cover for neonatal units. University Hospitals Sussex acknowledges that current on-call arrangements do not meet BAPM standards and is exploring options for a separate Neonatal Consultant on-call rota for the Princess Royal Hospital. They are approaching the Integrated Care Board (ICB) to consider externally reviewing current arrangements.

Noted (AI summary) NHS England states that they do not endorse a particular STREAMing model nationally and that the STREAMing pathway in use by Medway Maritime Hospital does not have an undue prioritisation of chest pain and that the pathway would likely not have altered the outcome of the initial assessment in this case. They also note that all reports are reviewed by the Regulation 28 Working Group. The Royal College of Emergency Medicine states that they are unable to comment on the specific concerns raised as they are unfamiliar with the STREAMing model and notes existing guidance and work with NHS England on initial assessments. NICE acknowledges the concerns but states that the issues raised are outside of their remit, as they relate to a system produced by NHS England.

Noted (AI summary) NHS England is reviewing its communications approach to alerting GP practices about medicine shortages and the Pharmacy and Medicines Optimisation Team is reviewing the use of AAIs and their supply. All reports received are discussed by the Regulation 28 Working Group. BSACI is developing an online allergy education platform for healthcare professionals and others, covering anaphylaxis recognition and management. The BSACI allergy action plans include difficulty swallowing as a manifestation of anaphylaxis and state "if in doubt, give adrenaline." The RCP will work with other colleges and societies to agree and support standards of care and education related to allergy, including updating standards for allergy accreditation and promoting multidisciplinary care. As a member of the EAGA, the RCP is working on the development of the UK National Allergy Strategy. The GDC will write to NICE to suggest they review anaphylaxis symptoms and guidance for dental professionals, and will consider changes to CPD requirements regarding medical emergencies as part of a review concluding in 2025. The GPhC acknowledges supply issues with adrenaline autoinjectors and highlights existing standards for pharmacy professionals, signposting other resources for safe AAI use and directing medicine supply inquiries to the DHSC. They offer a meeting with Hannah's family. The RCPCH will share information from the report with its members via a patient safety portal and for discussion with the Clinical Quality in Practice Committee, where further actions may be identified.

Noted (AI summary) NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National Primary Care Team will consider GP awareness of alerting ambulance services to specific conditions; the ICB will take the circumstances surrounding Margaret’s death to their GP learning sessions and consider a system-wide safety alert. AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient addresses. NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, and accepting care plans and flags from providers until an automated solution is available. They have also established an ICB-wide group to improve flagging challenges.

Noted (AI summary) NHS England acknowledges the coroner's concerns but states that NICE is the appropriate body to provide clinical guidance. NHS England will review NICE's response and consider any resultant actions, while noting the need for individualised care in such cases. They are also gathering information on a delay in reporting a CT scan result. NICE acknowledges the lack of specific guidance on restarting anticoagulants after traumatic intracranial haemorrhage. NICE will consider the issues raised through their guidelines surveillance process and discuss a consensus statement with relevant specialist societies.

Noted (AI summary) NHS England acknowledges concerns about oesophageal intubation and the PUMA guidelines and states they will clarify the future direction of the Never Events Framework. They also note that all PFD reports are discussed by a working group to share learnings. The organisations agree with the coroner's concerns and highlight their existing work, including the 'no trace = wrong place' campaign, endorsement of PUMA guidelines, and emphasis on capnography in anaesthesia standards. They also express support for unrecognised oesophageal intubation to be a nationally reportable incident. The RCEM expresses support for adequate staffing, multidisciplinary simulation training, equipment standardization, intubation checklists, and capnography use, referencing an existing framework for collaboration between Emergency Medicine and Intensive Care Medicine.