Child Death

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) DVSA acknowledges receipt of the coroner's report and notes that the Department for Transport will be responding on their behalf.

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 Sussex confirms that University Hospitals Sussex NHS Foundation Trust (UHSx) and East Sussex Healthcare NHS Trust (ESHT) have implemented policies regarding fluid management and hyponatraemia in labour, developed and delivered training and education, and are auditing compliance with fluid balance charts. A leaflet has been developed advising mothers about fluid intake in early labour and shared learning about hyponatraemia and fluid balance in labour with the Regional Maternity Team at NHS England in 2022. The NMC is carrying out Fitness to Practise investigations, has shared the PFD report with the GMC, and will develop and publish a scenario to inform student midwives and midwives about hyponatraemia for the start of the next academic year. The Royal College of Obstetricians and Gynaecologists expresses condolences and outlines its role in supporting maternity services through educational initiatives and clinical guidance. It refers to existing NICE guidelines and other resources related to fetal monitoring, intrapartum care, and hyponatremia, and suggests the Royal College of Midwives also be informed. The Department of Health and Social Care highlights the publication of an NHS Resolution report on hyponatremia and notes the rollout of the Brain Injury Reduction Programme across maternity units in England.

Noted (AI summary) The response consists of the organisation's name only.

Noted (AI summary) The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations. Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018.