Other related deaths

Action Planned (AI summary) The ENA has convened member companies to improve arrangements following the death. They plan to produce industry guidance on health and safety risk assessments for low-hanging overhead lines and promote innovative monitoring technologies by September 2026.

Action Planned (AI summary) Derby and Derbyshire ICB is working to remove barriers to information sharing by establishing system-wide information governance agreements and applying for Section 251 agreements by Q1 26/27. The ICB will also work with partner Trusts to ensure relevant guidance on information sharing and cross-referencing mother and baby notes is provided by Q1 26/27. NHS England has invested £20 million to connect care records across England by March 2026 and is updating its Healthy Child Programme guidance to include requirements for information sharing and record keeping related to maternal and family health. Regional Chief Nurses will cascade this updated guidance to Trusts. Sett Valley Medical Centre has implemented screen alerts on mother/child notes where the mother is under perinatal care and ensures these patients are discussed at monthly MDT and child safeguarding meetings. They also completed suicide prevention training and plan to request acknowledgement of referrals from the perinatal team. Derbyshire Healthcare NHS Foundation Trust has audited GPs not using SystmOne and added an 'alert' to patient records for awareness. They have drafted an information leaflet for GPs about different electronic record systems and added an additional page to e-referral documents for contextual information sharing. Derbyshire Community Health Services NHS FT has incorporated guidance into their Perinatal Mental Health SOP for cross-referencing child and parent records when information is relevant to parental mental health, and implemented an auto-consultation function in SystmOne for this purpose. Locality Managers have been briefed, and a one-page document on record keeping has been shared with staff.

Action Planned (AI summary) The Royal College of Pathologists will raise the issue of including IgE testing and cross-referencing other autopsy guidelines with the author group of the relevant autopsy guideline. Cambridgeshire Constabulary has established liaison with Scenes of Crime Officers, amended and re-issued internal procedural guidance, incorporated updated guidance into the 'SaferTogether' newsletter, and included revised processes in ongoing training cycles for child death investigations.

Action Planned (AI summary) The landlord will fit a grab rail on top of a wall to improve handrail safety and expects lighting work to be completed in 3 weeks. Signs advising of steep steps were installed soon after the property purchase, and a non-slip coating was applied to the steps.

Action Planned (AI summary) NHS England will publish new guidance, the Personalised Care Framework, to improve care for people with severe mental health problems needing help from secondary mental health services, emphasizing collaboration between services.

Action Planned (AI summary) The Welsh Government is adapting the Paul Ridd to roll it out to the social care workforce and the wider public sector, developing tier 2 and tier 3 training for health and social care professionals, and incorporating learning disability annual health checks into the GP Wales core contract.