Emergency services related deaths

Noted (AI summary) • The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform. • These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules. • This training is available for all police officers and staff across England and Wales.

Noted (AI summary) South Central Ambulance Service acknowledges concerns about handover delays but states the issue originates with hospital trusts and asks that future reports be directed to the appropriate organisation. It also describes NHS England initiatives and commissioned targets for handover times.

Noted (AI summary) EMAS is actively working with local mental health crisis teams to formalise referral pathways and will undertake an After Action Review on 8 January 2026 with all parties involved in the incident. Mental Health Awareness training is also under review for January 2026. The Trust provided bespoke training on the Mental Capacity Act for the Clinical Access Line and Crisis Resolution Home Treatment team. They also developed flow charts to support staff in considering mental capacity and shared these with staff, displaying them in team offices. The RCGP provides context on its role in setting standards and supporting GPs and highlights existing training resources. It suggests system pressures impact GP decision-making and there is an opportunity to address the system aspects of referral processes.

Noted (AI summary) The Trust is implementing dynamic strategic conveyance, directing patients to hospitals outside their usual catchment area. They are also working to implement the 45-minute handover protocol and initiate 'rapid handover' requests during periods of high demand. SCAS investigated the incident, finding one call non-compliant due to documentation errors, and shared learning with the call handler. It details actions taken when a 999 call is received and summarises the call cycle and audit outcomes. The Department acknowledges the concerns and outlines the government's commitment to improving urgent and emergency care. It highlights key actions from the Urgent and Emergency Care Plan and improvements in ambulance response times and handover delays, while noting SCAS has responded in full to the concerns. The hospital has been working through an UEC improvement programme since January 2025, including implementation of the national 45-minute maximum ambulance handover time standard, Frailty SDEC and Trusted Assessor introductions, and NerveCentre pre-arrivals screen. They have increased ambulance handover space and medical pathway by introducing RAU and AAU.

Noted (AI summary) The International Academies of Emergency Dispatch conducted an independent case review and found the EMD to be compliant with protocol; they note that a delayed response was likely a factor in the poor outcome.

Noted (AI summary) The Department for Health and Social Care acknowledges the concerns and outlines the Government's commitment to improving urgent and emergency care, referencing the 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, as well as improvements to ambulance response and handover times. They do not describe specific actions taken or planned as a direct result of this case.

Noted (AI summary) The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations.

Noted (AI summary) The First Minister for Wales acknowledges concerns about ambulance patient handover delays at Cwm Taf Morgannwg University Health Board and outlines the Welsh Government's governance and escalation processes for NHS organisations, noting that all health boards are in escalation for urgent and emergency care.

Noted (AI summary) The practice has amended its process for new baby registrations, including removing the 'unregistered babies' folder and updating the Docman system to allow electronic rejection of incorrectly sent correspondence. NHS England acknowledges the concerns about the NHS Pathways algorithm and details its function. It highlights existing access to clinical support for health advisors and refers to work by the Regulation 28 Working Group. The trust has already taken several actions including auditing the call, sharing learning through various channels, and providing training to staff. They have also reviewed and amended the NHS Pathways cardiac arrest algorithms following a previous case. The CQC contacted the provider, Unity Health, who confirmed they reviewed their processes and implemented a new system for creating a new profile when they are notified about a birth. They flagged this issue with the ICB and will be sharing details of this incident with the CQC’s Primary Care inspection teams.