Other related deaths

Noted (AI summary) Maidstone Hospital has implemented an action plan, recorded in their incident reporting system (DATIX), and taken steps to strengthen multi-professional working with Kent and Medway Social Care Partnership Trust. They have also commissioned an audit into consent and capacity practices and appointed a new clinical advisor and practitioner for capacity. Kent and Medway NHS and Social Care Partnership Trust have improved joint working with Maidstone and Tunbridge Well NHS trust, strengthened Mental Capacity Assessment monitoring, closely monitored Mental Capacity Act training and signed a Service level agreement with MTW to support patients detained under the Mental Health Act. The DWP outlines its procedures for vulnerable claimants, including reasonable adjustments for those unable to attend in person. They state that they are satisfied that appropriate support is available and do not propose to take any specific actions or make any changes at this time.

Noted (AI summary) The National Trust will conduct an immediate review of its risk assessment for Cock Marsh, including control measures and signage, and a signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures. There are plans for the Property Team to share this information Jordan's family and reviewing website visitor information. The Environment Agency acknowledges the coroner's concerns regarding safety measures at a specific site, but states that the National Trust, as landowner, holds primary responsibility for implementing measures like warning signs and rescue devices. The EA outlines its responsibilities as the navigation authority for the River Thames and its regular inspection of assets, but refers to case law indicating individuals should take responsibility for their own safety during potentially dangerous activities.

Noted (AI summary) Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of all active service user’s relevant information, and review of all service users at a face-to-face appointment. Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, regarding the transfer process. GMMH offers to meet with the coroner to discuss the transfer of services.

Noted (AI summary) The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.

Noted (AI summary) NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.

Noted (AI summary) The GMC updated its prescribing guidance in February 2021 to place greater emphasis on good practice principles regardless of consultation method and highlights the need for dialogue with patients and obtaining adequate history, including current medication use. The GPhC outlines its role in setting standards for registered pharmacies and pharmacy professionals and taking enforcement action when standards are not met, including actions against online pharmacies supplying high-risk medicines and referrals to Fitness to Practise process. CQC has been in formal discussion with DHSC and submitted proposals for legislative changes to improve risk management of online primary care providers, and is working with regulatory partners to ensure that gaps in regulation are mitigated. DHSC acknowledges the concerns and describes the regulatory framework for medicines, including the roles of MHRA and GPhC, without outlining specific actions beyond existing oversight.