Other related deaths

Action Planned (AI summary) Greater Manchester Health & Social Care Partnership acknowledges the potential gap in support for patients with complex needs and describes initiatives to improve data sharing, training, and oversight. They plan to present learning to the Greater Manchester Quality Board and cascade learning through governance and learning forums. The Department of Health and Social Care is implementing the Community Mental Health Framework (CMHF) to improve joined-up support across health and social care, aiming for all areas to have these models in place by the end of 2023/24. It also highlights increased collaboration through the Health and Care Act 2022 and the government's integration white paper.

Action Planned (AI summary) The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation.

Action Planned (AI summary) The Chief Dental Officer will reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners, and will cascade similar communication and guidance to NHS general medical practitioners.

Action Planned (AI summary) National Highways is upgrading traffic signs and road markings, including interactive electronic vehicle-activated signs, in the area of Stainmore Cafe Services. They do not plan to install lighting or widen the central reservation.

Action Planned (AI summary) The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.

Action Planned (AI summary) Great Yarmouth Borough Council and Caister-on-Sea Parish Council will discuss the shoreline management plan with parish councils, write to organizations and businesses near the shoreline, launch a social media campaign, and work with Coastal Protection East partners to increase public awareness of coastal management issues.

Action Planned (AI summary) The NPCC and College of Policing outline actions taken, including updating the Death Investigation Manual and associated training to emphasize treating deaths as suspicious until proven otherwise. They have also highlighted existing guidance on handling personal effects and assessing handwritten notes, and initiated a review of the Forensic Submissions Good Practice Guide. DCMS states that the Online Safety Bill will place new requirements on companies in relation to illegal content and anonymity online and services will have to identify, mitigate and effectively manage the risk of anonymous profiles. Ofcom will set out the types of verification methods a company could use in guidance. The Metropolitan Police Service has updated its Death Investigation Policy to emphasize treating deaths as suspicious until proven otherwise and is providing refresher training to detectives. The CONNECT Investigation platform, which is replacing CRIS, will have improved functionality to track the completion of investigative actions.

Action Planned (AI summary) The Ministry of Justice will issue an instruction to prison governors that no prisoner held in a segregation unit should be released on HDC and will prioritise necessary amendments to the Framework so that changes not being made immediately will be in place by the summer. An investigation has been instigated under Prison Disciplinary powers into the circumstances of the release including the decision made at HMP Ranby to withdraw the referral made to the independent adjudicator.

Action Planned (AI summary) The Department for Education is investing in educational resources to address knife crime and serious youth violence, and investing £45 million in two new programmes including Alternative Provision Specialist Taskforces and the SAFE Taskforces programme.

Action Planned (AI summary) HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training for front line court staff to identify and escalate safeguarding concerns. The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff were reminded to adhere to the 'probation risk to self' EQUiP process maps. London Probation published a new thematic Suicide and Self-Harm Performance and Quality Newsletter on 19 January 2022.