Other related deaths

Noted (AI summary) Transport for London has already procured, developed, and installed a bespoke Physical Prevention of Overspeed System (PPOS) on the London Tram network, reducing the risk of overturning by 76%. They are also investigating the feasibility of strengthening tram doors and will incorporate learnings into future fleet specifications. Bombardier Transportation (now Alstom) has completed a door vulnerability assessment, performed design reviews for current and future tram door systems, and engaged with suppliers regarding enhancements. They plan to finalize improvement actions and recommendations for door strengthening for both in-service and new tram fleets by March 2022, and engage with authorities to review UK regulation for light rail doors by April 2022. Tram Operations Ltd is already a member of CIRAS (Confidential Reporting for Safety) for anonymous staff reporting and publicises this to staff. Regarding passenger ejection through doors, they confirm they do not own the trams but welcome discussions with London Trams and would support implementation of strengthening if feasible. Transport Focus clarifies its limited remit and resources to initiate a centrally funded national tram passenger safety group. They state they will engage with operators on passenger safety issues brought to their notice and support any such group initiated by another body. The Department for Transport reports that the Light Rail Safety and Standards Board (LRSSB) has published guidance on driver inattention and speed management, and all tram networks in England now subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). DfT is also consulting on establishing a national tram safety group and supports LRSSB's planned work on automatic braking systems, door strengthening standards, and promoting CIRAS. The Light Rail Safety and Standards Board confirms that all seven UK tramways already subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). LRSSB further plans to produce a tramway-specific guidance note and communication campaign to promote the benefits of such schemes to front-line staff by March 2022. The Light Rail Safety and Standards Board is engaging with European Standards working groups to inform regulation on tram door security and crashworthiness, and plans to consult with TfL/London Trams to determine remedial actions. LRSSB will then publish a briefing or guidance note for the sector, with timelines to be confirmed. The LRSSB has published new Light Rail Guidance on Driver Inattention (LG3) and Light Rail Standards on Speed Management Systems (LS4), incorporating RAIB recommendations. They have also commissioned a trial of specific technology for driver inattention and speed management, with outcomes expected by January 2022.

Noted (AI summary) SECAmb issued a "Hot Topic" learning update to all 111 call handling staff in October 2021, emphasising the need to identify and refer complex cases to clinicians and provided training and guidance to ensure staff fully understand the diverse needs of patients. NHS Digital provides background information on the NHS Pathways clinical decision support software and its governance, deferring to other organisations to address specific concerns raised in the report.

Noted (AI summary) Devon and Cornwall Police are assured that they are dealing with reports appropriately where a dog poses a risk of serious harm, and will explore with the Police and Crime Commissioner the opportunities for enhanced public communication, potentially with our farming community and Local Authority partners in respect of dangerous dogs.

Noted (AI summary) The Department for Transport clarified that local authorities are responsible for hazard signage and highway maintenance, and that existing guidance is available but not mandatory.

Noted (AI summary) The Department for Transport explains current driver licensing arrangements and guidance for medical professionals, noting age is not an automatic barrier to driving, but they encourage drivers to discuss concerns with medical professionals, and points to an older driver website. The GMC has contacted the Royal College of General Practitioners (RCGP) to raise awareness of the risks of confusion related to UTIs and driving among their members.

Noted (AI summary) Jigsaw Homes Tameside states that its technician checked for alternative exits before boarding the door and the tenant had keys to the rear door.

Noted (AI summary) The Department for Levelling Up, Housing & Communities references existing building regulations, guidance, and the role of fire and rescue authorities, but does not commit to further action.

Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.