Other related deaths

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.

Noted (AI summary) TPP reports that functionality for seamless data sharing between GPs and prisons via SystmOne has been available since before 2019, but its use depends on GPs enabling data sharing. Since the death, full GP registration has been introduced in prisons allowing automatic electronic transfer of GP records to prison GPs, regardless of the system used by the community GP. EMIS reviewed its EMIS Web system focusing on interoperability with prison systems and transfer of medical records. EMIS asserts compliance with NHS England GP2GP specifications and states that no further software developments are required, but offers training materials and support to users.

Noted (AI summary) The NHS England Task & Finish Group on Analgesia is considering recommendations from the Manchester Arena Inquiry regarding paramedics administering mucosal fentanyl lozenges. The group has been provided with a copy of the coroner's letter for reference, and any recommendations will be considered by a future government.

Noted (AI summary) HMP & YOI Parc has provided notice to offender managers to notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode, including providing information relating to a prisoner’s intentions in terms of where they are going on the day of release. G4S will continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. West Midlands Police have updated their systems with prompts to improve the identification of those at increased risk and will work with MAPPA partners to ensure the coordinator role and new policy are understood and cascaded to relevant staff. BSMHFT will develop a sustainable engagement strategy with MAPPA, review the Prison Discharge Coordinator's role, and explore amendments to the Systemone interface in HMP Birmingham to record community mental health team involvement, anticipating a decision within a month. The health board acknowledges the concerns raised in the report but states that it has no jurisdiction/power over the actions required for some of the concerns. However, it has alerted the MAPPA Coordinator to the concern regarding release of high-risk prisoners and will participate in Strategic Management Board discussions. West Midlands Probation Service is working with NHS-England Reconnect Service to ensure Probation Practitioners are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community. West Midlands Probation Service will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.

Noted (AI summary) The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations. Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018.

Noted (AI summary) Derby City Council has made changes to manage mentally disordered offenders, including working alongside the Forensic Community Mental Health Team and finalizing a Memorandum of Understanding to employ a Senior Social Work Practitioner. They also introduced regular training for social supervisors and a rolling programme of Unconscious Bias training. Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, which has undertaken shared cultural awareness training with the police and probation. The Trust has adopted Systm1 as its electronic patient record system and conducts ongoing record keeping audits. Derbyshire Constabulary has strengthened the protection offered to vulnerable people via civil orders and Stalking Protection Orders. The force has a comprehensive programme of activity to raise standards and improve record keeping, and all officers and staff now receive training on cultural aspects. Cygnet has reviewed the PFD action plan at Clinical Governance meetings and shared it with relevant teams; all staff complete a report writing and record keeping Skill workbook, and Cygnet audits on triangulation of records are completed 3 monthly. Response is a placeholder document.

Noted (AI summary) The BHPA states it is not a regulatory authority and has no powers of compulsion. They will continue to encourage people who wish to fly aircraft to join the Association and to undertake and complete their training programmes. The CAA will publish new safety guidance on maintaining the airworthiness of SPHG aircraft, incorporated into the Paramotor Code by September 2024. They will also begin a project by November 2024 to explore ways to improve pilot performance and knowledge, including assessing the need for additional training regulation.

Noted (AI summary) Hull University Teaching Hospitals acknowledges the coroner's concerns regarding discharge information, but clarifies that a Trusted Assessor Referral Form (TARF) detailing the patient's frailty and mobility was completed and submitted to Social Services. The hospital also noted the discharge summary included a request to the GP to follow up on blood pressure.

Noted (AI summary) The Food Standards Agency will raise the coroner's report at the next cross-government Food Supplements Working Group and contact relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. Save on Supplements Ltd expresses condolences and states it complies with applicable law, provides information on its website and packaging for safe consumption and reviewed its operations following the inquest. It will consider implementing changes if the regulatory landscape changes. The Department of Health and Social Care discussed the issues raised in the PFD report at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised. They have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.

Noted (AI summary) Energy UK expresses condolences and notes that it does not represent all energy network companies. It outlines existing industry practices regarding meter placement, safety checks, and support for vulnerable customers, referencing Ofgem guidance. Ofgem introduced new rules in November 2023 restricting suppliers from involuntarily installing prepayment meters for specific vulnerable customers, and suppliers are now required to assess the safety of prepayment meters annually.

Noted (AI summary) NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for young people up to 25, and existing guidance for GPs. Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information sharing, and safeguarding training as part of their professional training.