Other related deaths

Noted (AI summary) FCDO confirms that a response is still outstanding, but that they transmitted the report to the British Consulate in Crete for onward transmission to the relevant Greek authorities. They cannot guarantee a response from the Greek authorities.

Noted (AI summary) NICE acknowledges the lack of evidence for specific DOAC reversal protocols and states that clinical judgement is required. They reference existing guidance on head injury and andexanet alfa, and commit to monitoring new evidence.

Noted (AI summary) The Department of Transport refers to existing published guidance for users of e-cycles and e-scooters on battery safety, and states that pending the outcome of further research, no additional action is appropriate at this stage. The West of England Combined Authority states that specific actions to address the concerns raised by the Coroner do not lie within its strategic functions, requiring national government action in the first instance. They believe their provision of on-street rental e-scooters, e-bikes, and e-cargo bikes reduces the number of privately owned vehicles kept at home. OPSS has undertaken a program of work including commissioning research, engaging with gig economy firms to share safety information, and working with other government departments to publish guidance on e-bike and e-scooter safety. A new safety campaign with consumer messaging is expected to launch in the autumn.

Noted (AI summary) Supreme Care Services Ltd has reviewed all service users' pendants and undertakes weekly checks, reporting faults to the telecare provider and local authority. They also recommend clear flowcharts from the telecare provider and local authority on actions to take when equipment is faulty. TEC Quality describes the TEC Services Association's role as an independent industry expert and the Quality Standards Framework (QSF) used to audit service providers. They advocate for commissioners to specify the QSF in tenders but do not indicate specific actions taken or planned in response to the report.

Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.

Noted (AI summary) NHS England acknowledges concerns about secondary healthcare in prisons, particularly staffing shortages, but focuses its response on NHS England's remit. They have engaged regional colleagues and will consider responses from other Trusts, while also highlighting national work on PFD reports. Berkshire Healthcare has continued developing the One Team model, implemented monthly audits of Community Mental Health Team caseloads, and conducted various training programs (suicide awareness, trauma-informed care). They have also improved VCSE engagement and reinforced MAPPA escalation processes. Oxford Health NHS Foundation Trust will consider introducing guidance for psychological therapy staff about recording when an individual declines treatment in prison, to include guidance that declined offers of treatment are always considered in caseload management supervision. Thames Valley Police details actions taken by both the force and Counter Terrorism Policing South-East, including improvements to intelligence dissemination, Prevent training, MAPPA procedures, and Operation Plato. A multi-agency exercise was conducted to test the effectiveness of the Operation Plato plan. Midlands Partnership NHS Foundation Trust has refreshed the psychology pathway and updated referral criteria, and is standardising practice in regard to psychological care pathways. They have also developed a pilot of the Mental Health & Wellbeing Practitioner role and provide ongoing training for staff. The Ministry of Justice outlines changes to probation and prison procedures, including enhanced risk assessment tools, improved information sharing through MAPPA, and updated training for staff. These changes aim to better manage individuals who pose a terrorism risk. The Home Office describes ongoing improvements to the Prevent programme including reviews, case assurance, and annual statistics. They are implementing improved information sharing practices and conducting assurance reviews of training and processes related to discontinuing impending prosecutions.

Noted (AI summary) The DHSC refers concerns to the Cornwall and Isles of Scilly Integrated Care Board, notes new guidance for discharge from mental health settings, and explains why they do not believe ICB representatives attending MASH meetings would reduce risk but describes no specific action. The ICB will work with place-based directors to develop options for addressing the GP gap in safeguarding processes, including the adult MASH, consulting with stakeholders, presenting options to the executive group, and preparing a business case for funding if required.

Noted (AI summary) Greater Manchester Police acknowledges the absence of a specific policy on handcuffing during search warrant executions, but states that use of force is a case-by-case decision guided by legislation, the National Decision Model, and consideration of occupants' vulnerabilities.

Noted (AI summary) The Department for Transport explains the current driver licensing arrangements, emphasizing the legal requirement for drivers to report medical conditions to the DVLA and that the DVLA can only act on information received from licence holders and/or healthcare professionals about known medical conditions. They mention a Call for Evidence to gather views on the legislative framework that governs driver licensing for people with medical conditions.

Noted (AI summary) The Minister acknowledges concerns about mental capacity assessments for patients with chronic alcohol dependence and refers to existing legal frameworks like the Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005, noting practitioners must stay up-to-date with case law.

Noted (AI summary) NHS England acknowledges the concerns regarding epilepsy patient reviews and medication management, highlighting existing NICE guidelines, RCGP eLearning resources, and tools for structured reviews. They note workforce capacity challenges and share the report with regional colleagues, also describing the Regulation 28 Working Group. The Royal College of Physicians supports the Association of British Neurologists' position regarding national guidance on epilepsy monitoring, annual follow-up in primary care, and the need for clear communication in discharge letters. They highlight the low number of neurologists and epilepsy specialist nurses in the UK. The RCGP plans to highlight NICE guidelines and educational material on SUDEP through its Clinical Networks and member forums. It will also recommend to NHS England the need for standardised urgent care pathways for epilepsy patients and address issues relating to waiting times for appointments.