NHS England

Noted (AI summary) NHS England acknowledges the concerns raised, noting the national Liaison and Diversion service specification requires timely information sharing with police. They also describe national NHS England work on reviewing PFD reports to identify emerging trends. Midlands Partnership NHS Trust, which now provides Liaison and Diversion services in Sussex, has introduced a Custody Pathway Standard Operating Procedure. They are also considering extending their service hours and introducing an on-call service and are working with Sussex Police and Mitie to agree on the content of a revised MOU. Sussex Police references existing College of Policing guidance on handover procedures, risk assessments, intoxication, and mental vulnerabilities. They state they will not create a separate MOU due to concerns it could conflict with or become outdated compared to national guidance. The NPCC is considering a nationally recognised pre-arrival risk assessment to communicate risks and concerns to custody. They also plan to raise concerns regarding a lack of 24-hour LDS service and NHS Trust information sharing with NHSE. Mitie acknowledges the coroner's concerns regarding communication and documentation but states that they are not involved in mental health assessments in police custody and that the concerns should be addressed by the Police, NHS England and its local mental health and liaison and diversion services teams. However, Mitie has liaised with Sussex Police and the L&D Trust to understand their role in any formal process that they may wish to put in place.

Noted (AI summary) NHS England has engaged with Newcastle upon Tyne Hospitals NHS Foundation Trust, who have permanently suspended use of the cannula in question. All reports received are discussed by the Regulation 28 Working Group. The DHSC acknowledges the concerns, explains the roles of NHS England, MHRA and CQC, and outlines the NSDR's role in managing medical supply disruptions. They note that the supply disruption was not escalated to NSDR and that the MHRA has no evidence of excess risk with the cannula used.

Noted (AI summary) NHS England acknowledges the concerns raised in the report and refers to the SEL ICB's review of the case and the local authority's commissioning of drug and alcohol rehabilitation services. It also mentions the Regulation 28 Working Group which shares learnings from PFD reports across the NHS. DHSC acknowledges the concerns, outlines commissioning responsibilities for drug and alcohol services, and notes the existence of relevant NICE guidance and quality standards. They mention a Pan-London Inpatient Detoxification Programme and ongoing work to develop sustainable inpatient detoxification provision in London. The Ministry of Housing, Communities & Local Government states that they will not be responding to the report as officials do not consider that there is a specific policy angle here for them to respond to, and that the Department for Health and Social Care will be the lead Department responding to this report.

Noted (AI summary) NHS England acknowledges the concerns raised about the link between menopause and mental health decline and highlights existing NICE guidance. They also describe the role of the Regulation 28 Working Group in sharing learnings nationally. Somerset NHS Foundation Trust established a multi-disciplinary task and finish group to create guidance for clinicians on considering menopause/perimenopause during assessments, and plans to share the guidance in the coming weeks. They are also exploring national resources through the Newson Health Menopause Clinic. NICE is currently updating its guideline on menopause: diagnosis and management [NG23] with publication expected on 7 November 2024 and following publication, their surveillance team will assess if any further changes relating to mental health and menopause are needed.

Noted (AI summary) NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe internal processes for reviewing PFD reports. The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also provided guidance on assessing patient capacity and detaining patients under Section 5(2) of the Mental Health Act, including notification procedures and patient rights. The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A Joint Working Protocol is being put in place and the SLA between MSE and EPUT is being addressed at a senior level.

Noted (AI summary) NHS England acknowledges the concerns raised but states that they fall under the remit of East Suffolk & North Essex NHS Foundation Trust; they note that the Trust has taken learnings and is taking actions to ensure staff have Immediate Life Support training and that Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group. East Suffolk & North Essex NHS Foundation Trust has implemented actions including mandatory immediate life support training for certain staff, and monthly quality audits of resuscitation trolleys.

Noted (AI summary) NHS England highlights the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, designed to localize and realign care. They have published a Commissioning Framework and required ICBs to develop 3-year plans to cease sending people to distant or outdated inpatient services and are working with the Greater Manchester ICB re oversight of The Priory Cheadle. The DHSC acknowledges concerns about mental health service funding, reliance on independent providers, and availability of specialist units. They highlight existing initiatives to improve patient flow, localise care, and ensure quality regardless of provider.

Noted (AI summary) NHS England acknowledges the concerns and explains that interstitial lung disease is listed as a side effect in relevant resources. They suggest the coroner direct concerns about nilotinib and guidance to the MHRA. They also note work is being done nationally to share learnings from PFD reports. The MHRA has added the side effects experienced by Mrs. Mclaughlin to the Yellow Card database and requested the BNF editorial team consider including interstitial lung disease as a separate side-effect term in the nilotinib drug monograph; this will be included in the January 2025 online updates of BNF and BNFC.

Noted (AI summary) NHS England highlights increased access to CYPMH services, with 758,000 children and young people receiving support in the 12 months to January 2024. They cite a 46% increase in the CYPMH workforce since January 2019 and mention the NHS Long Term Plan's ambition for 100% access to specialist support. They also note discussion of all PFD reports by a working group. The DHSC acknowledges concerns about long waiting times for assessment and treatment in children and young people’s mental health services, and the importance of early intervention and support. They highlight the government's plans to increase mental health staff and improve access to services, and state NHS England will address concerns about the “keeping in touch team”.

Noted (AI summary) NHS England explains the NHS Pathways triage system and how it handles repeat calls, noting that ambulance services have local procedures for managing duplicate callers, including a geofence and other differentiating factors. They also highlight the use of the 'what3words' function to support location identification. West Midlands Ambulance Service explains their call taking protocols, addressing how they manage duplicate/repeat calls and clarifies the circumstances surrounding the delayed ambulance response, attributing it to significant hospital handover delays. They state the ambulance crew initially went to the kidney treatment center because they were unaware Mr. Fray had returned home.

Noted (AI summary) NHS England expresses condolences and states that concerns have been listened to and reflected upon. They highlight the remit of other organisations (NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust) regarding some of the concerns, and reference workstreams to increase ambulance capacity and improvements to Tameside's ED. They also note the discussion of PFD reports by their Regulation 28 Working Group to share learnings.

Noted (AI summary) NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.

Noted (AI summary) NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.

Noted (AI summary) NHS England acknowledges the concerns about mental health bed shortages and highlights ongoing investment in mental health services and the Better Care Fund. They are seeking further information from the North West region and will discuss the report at the Regulation 28 Working Group.

Noted (AI summary) NHS England acknowledges concerns about secondary healthcare in prisons, particularly staffing shortages, but focuses its response on NHS England's remit. They have engaged regional colleagues and will consider responses from other Trusts, while also highlighting national work on PFD reports. Berkshire Healthcare has continued developing the One Team model, implemented monthly audits of Community Mental Health Team caseloads, and conducted various training programs (suicide awareness, trauma-informed care). They have also improved VCSE engagement and reinforced MAPPA escalation processes. Oxford Health NHS Foundation Trust will consider introducing guidance for psychological therapy staff about recording when an individual declines treatment in prison, to include guidance that declined offers of treatment are always considered in caseload management supervision. Thames Valley Police details actions taken by both the force and Counter Terrorism Policing South-East, including improvements to intelligence dissemination, Prevent training, MAPPA procedures, and Operation Plato. A multi-agency exercise was conducted to test the effectiveness of the Operation Plato plan. Midlands Partnership NHS Foundation Trust has refreshed the psychology pathway and updated referral criteria, and is standardising practice in regard to psychological care pathways. They have also developed a pilot of the Mental Health & Wellbeing Practitioner role and provide ongoing training for staff. The Ministry of Justice outlines changes to probation and prison procedures, including enhanced risk assessment tools, improved information sharing through MAPPA, and updated training for staff. These changes aim to better manage individuals who pose a terrorism risk. The Home Office describes ongoing improvements to the Prevent programme including reviews, case assurance, and annual statistics. They are implementing improved information sharing practices and conducting assurance reviews of training and processes related to discontinuing impending prosecutions.

Noted (AI summary) NHS England highlights the Suicide Prevention Strategy and guidance to improve the culture of care for mental health inpatient services. Oxleas has designed a clinical risk training workshop, and participates in the Royal College of Psychiatrists’ Culture of Care Programme. The Department acknowledges concerns about the use of risk assessment tools and refers to NICE guidance and the 5-year Suicide Prevention Strategy for England. It highlights NHS England's work to improve risk management within mental health services, including guidance published in April 2024. The Trust will issue a blue light bulletin reminding clinical staff to update risk assessment documents, and will audit risk assessments using the 'Tendable' system. The Trust will also work with the National Culture of Care team to adapt the risk assessment and formulation tool.

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) NHS England expresses condolences and notes the concerns, but states that treatment for substance misuse is not within their remit. They highlight the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The Department acknowledges concerns about residential and detoxification facilities for young people, but states that inpatient detoxification is rare and should be managed by community services with hospital support. They highlight existing funding and support for local authorities to improve drug and alcohol treatment, and will keep service models under review.

Noted (AI summary) NHS England expresses condolences and refers to NICE guidance on Apixaban. They highlight that the Regional Chief Pharmacist in the Midlands will review the report and consider learnings for ICBs. They note that the local trust is best placed to address concerns around communication and access to records and that their regional Midlands colleagues have made the ICB aware of the concerns. NICE will further consider the issues raised through their guideline surveillance process to see if an update to the guideline is required and will share the report with Agilio Software for their awareness. The Department acknowledges concerns about national guidance on DOACs and communication between medical staff. They note existing NICE guidance and resources from the British Society for Haematology. CQC will contact the Trust Chief Pharmacist to establish whether the pharmacy was informed and involved in the outcomes of the Trust investigation. The Trust revised its view on the likely cause of the stroke. Bespoke Immediate Life Support sessions have been run across the Cardiology unit, delivered by the Resus Team and Cardiology ACPs. Safety Practice Alerts will be issued reminding staff of clear documentation re stopping/re-starting of DOACs, to be reviewed daily, and the alerts will be incorporated into the Trust's updated Oral Anticoagulant Guideline. The trust will also improve handover processes and ensure the new Electronic Patient Record system highlights information around pausing medication. Audits will be performed in 2026.