Other related deaths

Action Planned (AI summary) The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.

Action Planned (AI summary) The Scottish Government will work with SFRS to consider updating fire safety guidance for premises with sleeping accommodation, focusing on emergency fire action plans including procedures for checking evacuation and communicating with SFRS. SFRS will refresh prevention awareness internally, work with the hotel sector, engage with Dutyholders, and prepare a public education campaign on fire action plans.

Action Planned (AI summary) The Department of Health and Social Care directs readers to the Talk to FRANK website, mentions contact with the Home Office re: powers under the Psychoactive Substances Act 2016, and plans to invest £2.5m in piloting an enhanced RECONNECT service for offenders with complex needs.

Action Planned (AI summary) The Trust will deliver mandatory training in learning disability and autism for all health and social care staff, piloted from April 2021. Learning from Autism Deaths Thematic Review will be included in training and future service developments, monitored through a Quality Improvement Plan.

Action Planned (AI summary) East Sussex County Council is developing a potential pedestrian crossing scheme on the A2100 Battle Hill, with preliminary design completed and funding allocated in the 2021/22 Capital Programme for further development, subject to consultation and legal agreements.

Action Planned (AI summary) The Isle of Wight Council will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction. Ringway Island Roads will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction.

Action Planned (AI summary) CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online prescribers, working with other regulators and government organizations to address current and emerging threats. The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from a review focusing on medicines associated with dependence, including structured medication reviews for patients.

Action Planned (AI summary) Capita is pausing the issue of appointment letters during Change of Assessment or Further Review periods. They are also working with DWP to review the tone and language in written communications. Full implementation of the changes will be in place by 30 September 2021. The DWP has already introduced a highly visible "watermark" in the PIP computer system showing if a customer has additional support needs. Script changes to better support vulnerable claimants will go live by the end of May 2021, and strengthened wording regarding DLA will be introduced by early May 2021.

Action Planned (AI summary) Epilepsy Action will amend its online information by the end of June 2021 to extend advice about bathroom doors to any door to any confined space. It will also publish an article in its magazine and notify healthcare professional contacts about the issue. The RCPCH will share learning from the death with paediatric specialty groups and OPEN UK to raise awareness of home environment risks for children with epilepsy. They also suggest SUDEP Action could adjust advice on door opening in their resources.

Action Planned (AI summary) NHS England will explore adding guidance to ambulance call scripts to advise callers to go to the nearest emergency department (noting that not all hospitals have them) if they choose to transport the patient themselves. This will be explored through the Ambulance Transformation Forum.

Action Planned (AI summary) The Ministry highlights existing powers for local authorities regarding planning enforcement and building regulations. They plan to introduce stronger enforcement powers as part of planning system reforms and are consulting on proposals to mandate and improve smoke alarms in rented homes.