Other related deaths

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. 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. 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. 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. 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.

Action Planned (AI summary) The HSE will raise the coroner's concerns at an upcoming WRDP National Liaison Committee (NLC) meeting, recommending refresher communications to signatory organizations, providing an update on national training material for work-related elements of investigations, and providing an update on a proposed 'Suspected Gas Explosion checklist'. They will also provide the Senior Coroner with HSE guidance related to gas safety investigations. South Wales Police will raise the coroner's concerns with the National Liaison Committee regarding the Work Related Death Protocol and collaborate with the HSE and other signatories to ensure any appropriate amendments are made to the protocol. They also noted that they will work with the HSE to ensure the service is able to gather evidence and information needed to identify the cause of explosion.

Action Planned (AI summary) The RCGP has commissioned internal work through their elearning team to highlight the specific issue of interpretation of the Wells score. This will be published and available to members in the first quarter of 2026 and promoted through their members network and Chair’s blog. An Electronic Safety Notice has been issued to prevent steering system misalignment checks being missed on MOD Land Rovers. Work is also underway to update the inspection criteria for MOD Land Rovers to provide a comprehensive and long-term solution.

Action Planned (AI summary) The Department for Education will set out plans to significantly increase foster care numbers, backed by additional funding and investment in regional recruitment support hubs and a foster care retention model called Mockingbird. Rotherham Metropolitan Borough Council will continue to pursue their Looked After Children and Care Leavers Sufficiency Strategy, make improvements to documentation, recording and approval processes, and enhance risk assessment processes.

Action Planned (AI summary) The NFCC is working with Humberside Fire and Rescue Service to share learning from the incident via the NFCC Organisational Learning platform. The letter also states that the Secretary of State at the Department of Health and Social Care (DHSC) will be made aware of comments concerning rights of access for ambulance personnel. The National Police Chiefs Council has established a group to review and track coroner’s reports relating to the application of Right Care, Right Person, and any learning will be disseminated and policy amended as needed.