Child Death

Noted (AI summary) NHS England is increasing access to CYPMH services, with 702,000 children and young people receiving support in the 12 months to June 2023 and a 46% increase in the CYPMH workforce since the start of the LTP. They will also ensure regional leadership are aware of the report's findings and the Regulation 28 Working Group will discuss all reports received. NELFT will implement the Oxford Centre for Suicide Research’s model of risk formulation and co-produce safety plans with clients and families, including training and system changes to support the roll out. NHS North East London is developing a business case for additional CAMHS funding, including proposals for seven-day/evening working and face-to-face initial assessments. They are also reviewing the current clinical model and participating in transformation work via their Mental Health, Learning Disability and Autism Collaborative. The Department of Health and Social Care acknowledges concerns about CAMHS resourcing and highlights increased spending on mental health services and workforce development initiatives, including training programmes and a new suicide prevention strategy.

Noted (AI summary) Festival Republic implemented improvements for Leeds Festival 2023, including enhanced security at gates, search operations, presence of dogs, visible messaging, and covert operations. They addressed medical facilities concerns by improving the Forward Operating Base, triage processes, ambulance resourcing, and welfare support. They also plan to consider further improvements for the 2024 festival. Leeds City Council, via its Licensing Committee, detailed enhancements made by Festival Republic for the 2023 Leeds Festival, including improved security and stewarding, SIA-accreditation checks on security staff, enhanced staff manuals, daily briefings, and new AIR Hubs. Arrest data analysis suggests Festival Republic's drug security strategy was effective, with increased arrests and drug-related arrests in 2023. Festival Republic provides updated arrest statistics from West Yorkshire Police regarding drug offenses at an event. West Yorkshire Police increased measures to combat drug supply at the 2023 Leeds Festival, including a dedicated intelligence researcher, liaison with other festivals, robust searches at ingress points, increased use of drug dogs, covert operations, and a WYP officer stationed in the Festival Republic Control Room, resulting in more arrests. They will also ensure a dedicated detective inspector attends the hospital with the ill person in future. The Home Office highlights government efforts to tackle illegal drugs through police action, reducing demand, and improving treatment. It notes that organisations wishing to deliver back-of-house drug checking facilities at festivals can apply for a license.

Noted (AI summary) NHS England are committed to moving to a ‘0-25 year service model’, offering person-centred and age-appropriate care for mental and physical health needs. A Patient Safety Bulletin was issued highlighting the need for ‘prompt measurement of ammonia and action in the event of hyperammonaemia’. The FSA expresses condolences and explains its responsibilities for food safety, noting that nutritional advice and labelling are the responsibility of the DHSC, to whom they will forward the report.

Noted (AI summary) NHS England refers to the RCOG guidance on assisted vaginal birth and highlights the need for clinicians to be aware of the guidance and assess the advantages and disadvantages of available delivery techniques; the results of the ROTATE trial will be carefully reviewed. Following inaccurate assessments of fetal head position by clinicians prior to starting procedures, RCOG advises that ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination. Updated RCOG Green-top Guideline No. 26 provides recommendations to support practitioners around the use of instruments for assisted vaginal births.

Noted (AI summary) TfWM's new e-scooter operator Beryl will use the same 'selfie' security process for registering an account as the previous operator, Voi. They will work with local police and schools to identify and act on underage riding reports, and will monitor bank account registrations. Beryl will also implement outreach work with institutions and academies. The Department for Transport will encourage operators to continue additional measures to deter under-age riding, and will work with trial operators to gather and disseminate examples of additional measures. They will also work with operators to understand if anything more could be done to alert them to attempts by under-age riders to gain access to e-scooters. CoMoUK acknowledges the concerns but states they don't have the power to make operational changes to shared transport schemes. They have held meetings with Transport for West Midlands and the Department for Transport and will track the changes being implemented.

Noted (AI summary) Sheffield Children's NHS Foundation Trust has improved induction training for junior doctors, providing information on when to escalate concerns to senior staff, particularly regarding reattenders, fever, chicken pox and sepsis. They have reminded primary care of the current referral system and will ensure patients arriving with GP letters are seen by the appropriate team. Sheffield Children's NHS Foundation Trust CEO expressed apologies to the family and outlined the various actions taken, including a meeting with the family and a presentation to the Trust Board to emphasize learnings from the case.

Noted (AI summary) NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat should be considered. They highlight that a specific guideline on Group A streptococcus has not been requested and that rapid tests were not recommended for routine adoption. MFT expresses concern for better clinician awareness of GAS and its management, and has liaised with relevant bodies to raise their concerns. They recommend the development of comprehensive, nationwide guidance for clinicians on GAS, similar to existing guidance for meningococcal disease. The Department of Health and Social Care highlights NHS England's interim clinical guidance on Group A Streptococcus and a public campaign to inform parents about symptoms. They also mention plans to implement Martha's Rule to allow rapid review of deteriorating patients. The RCPCH has shared information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and will share the information for discussion with the RCPCH Clinical Quality in Practice group in October.

Noted (AI summary) NHS England has worked with South London and Maudsley NHS Foundation Trust, who have identified dual diagnosis leads, established a CAMHS Dual Diagnosis forum, incorporated learning from Serious Incidents into team meetings, and are holding briefing sessions on AUDIT completion requirements. All reports received are discussed by the Regulation 28 Working Group. The Department of Health and Social Care acknowledges the concerns and refers to NHS England's response. It also mentions national initiatives for mental health and substance misuse services, including increased funding and commissioning quality standards.