Child Death

Noted (AI summary) The National Trust will conduct an immediate review of its risk assessment for Cock Marsh, including control measures and signage, and a signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures. There are plans for the Property Team to share this information Jordan's family and reviewing website visitor information. The Environment Agency acknowledges the coroner's concerns regarding safety measures at a specific site, but states that the National Trust, as landowner, holds primary responsibility for implementing measures like warning signs and rescue devices. The EA outlines its responsibilities as the navigation authority for the River Thames and its regular inspection of assets, but refers to case law indicating individuals should take responsibility for their own safety during potentially dangerous activities.

Noted (AI summary) NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty.

Noted (AI summary) NHS England acknowledges concerns about transitioning young people from CAMHS to adult mental health services, explains the current policy, and notes work has commenced regarding community transformation and development of a 14-25 Transition service. North Staffordshire Combined Healthcare NHS Trust will review the Transition of Young People to Adult Mental Health Service Policy, and explore options for a designated in-patient service or unit for young adults.

Noted (AI summary) SECAmb issued a "Hot Topic" learning update to all 111 call handling staff in October 2021, emphasising the need to identify and refer complex cases to clinicians and provided training and guidance to ensure staff fully understand the diverse needs of patients. NHS Digital provides background information on the NHS Pathways clinical decision support software and its governance, deferring to other organisations to address specific concerns raised in the report.

Noted (AI summary) Devon and Cornwall Police are assured that they are dealing with reports appropriately where a dog poses a risk of serious harm, and will explore with the Police and Crime Commissioner the opportunities for enhanced public communication, potentially with our farming community and Local Authority partners in respect of dangerous dogs.

Noted (AI summary) NHS England is integrating care with a focus on addressing inequalities and supporting vulnerable children and families, and will work to raise the profile and uptake of the Healthy Start programme which is in the process of transferring from paper vouchers to digital cards. The Department of Health and Social Care acknowledges the concerns, states that national data does not show a significant increase in diagnoses of iron deficiency anaemia, and outlines existing schemes such as the Healthy Child Programme and Healthy Start scheme aimed at promoting healthy diets. They do not plan to introduce new policies specifically targeting nutritional anaemia.

Noted (AI summary) The response acknowledges the death and outlines current NICE guidance on managing large babies and gestational diabetes, noting an ongoing trial on inducing labour for predicted macrosomia.

Noted (AI summary) NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing NICE and GMC guidance on sharing information and safe medicine use. The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health records and safe transfers of care. The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share learnings from the case with stakeholders and encourage pharmacies to work more effectively with healthcare teams. The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, RPS, and NHS England) to consider how practice can be improved.