Other related deaths

Noted (AI summary) Leeds City Council acknowledges the coroner's concerns regarding a lack of legal powers to access properties for safety works without tenant consent. The council states that granting additional legal powers to landlords is a matter for central government. The Home Office acknowledges the coroner's concerns about fire risks in social housing but explains the existing regulatory framework, including the Regulatory Reform (Fire Safety) Order 2005 and the Housing Health and Safety Rating System. It highlights the role of Fire and Rescue Authorities and the Home Office's Fire Kills campaign.

Noted (AI summary) NHS England highlights national initiatives to improve digital systems, workforce, and mental health services, including the Long Term Workforce Plan and the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. All reports received are discussed by the Regulation 28 Working Group. BSMHFT is working jointly with the Integrated Care System and highlights other areas to assist with lack of resources, including 3 Places of Safety available. The Shared Care Platform has been enhanced allowing different organisations to access different clinical information across the system. NHS Birmingham and Solihull ICB clarifies that GPs are not contractually required to monitor the collection status of medicines that they have prescribed. Birmingham City Council is working with NHS partners on a new Memorandum of Understanding to increase AMHP capacity and will fund AMHP training for NHS staff. They also trained 8 AMHPs in 2022 with funding from Skills For Care and aim to train 5 per year. The Department of Health and Social Care acknowledges the concerns, highlights existing investment in mental health services and workforce, and points to integration of services through integrated care systems and the Major Conditions Strategy.

Noted (AI summary) The Department for Transport acknowledges the coroner's concerns but states it has limited power to intervene and that the Office of Rail and Road and London Underground Limited are responsible. It notes that London Underground Limited has reached an agreement with its contractors and will provide details to the coroner. Transport for London states that KONE engineers will undertake all inching activities on LU's moving walks and escalators. TfL is working with KONE to update Safe Systems of Work by 29 September 2023 to reflect these new arrangements.

Noted (AI summary) The GPhC acknowledges receipt of the concern regarding Orchard 2000 Pharmacy and provides context about its role as a regulator of pharmacy professionals and premises, but does not describe any specific actions taken or planned in response to the concern. The GPhC notes concerns about the roles and responsibilities of delivery agents and states that the Superintendent Pharmacist has updated SOPs to clarify how delivery drivers should respond to emergencies, including contacting emergency services and informing the pharmacist. Delivery drivers are also enrolled on a specific training course. Orchard 2000 Pharmacy has made delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty in emergencies. They have also enrolled delivery agents in a training program titled 'Delivering Medicines Safely and Effectively'.

Noted (AI summary) Dorset and Wiltshire Fire and Rescue Service states its commitment to the Joint Emergency Services Interoperability Principles (JESIP) and highlights that the challenges of intra-operability with partners is an area of focus for the Blue Light Group on 18 September 2023. Dorset Police has updated the Niche system by adding a drop-down list regarding Google Translate translation software. They are also implementing changes to Section 2 of Occurrence Logs on Niche, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question. HM Coastguard updated its Capability Matrix to provide partner emergency services across the UK with information on its communications capabilities and uploaded it to the MCA's ResilienceDirect page. 'Connect' call capabilities also now feature in routine exercising with other stakeholders and during the Emergency Control Room visits. The National Fire Chiefs Council (NFCC) supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP) doctrine and will commence work in autumn 2023 to establish a process of providing additional national assurance about the application of JESIP across blue light services. The Trust outlines its existing communication protocols with other emergency services, including ambulance dispatchers' ability to communicate with air ambulances and telephone links with SAR aircraft via the Maritime and Coastguard Agency. It says its staff endeavour to use clear language in all communications, adhering to JESIP principles. NHS England acknowledges concerns but notes many fall outside its remit. It encourages local systems to consider accessibility of resources and highlights agreed actions between Dorset Healthcare Criminal Justice Liaison and Diversion Team and Dorset Police to improve working practices. NicheRMS circulated the facts of the coroner's report to Niche Technology customers and is seeking views on changes needed to reduce the chance of a similar occurrence. A temporary solution is proposed, pending consultation with all Niche forces, that will involve staff making the appropriate detention log entry as occurs for other risk assessment questions. The College of Policing will amend the Detention and Custody APP checklist to include a question about previous arrests. Once this amendment has been made the College will write to forces informing them of the change. NPAS and HMCG have agreed to a series of joint familiarisation briefings for all staff and will develop a joint "quick action card" prioritising the need for the Host Force to set an Emergency Services channel on Airwave. Monthly Comms meetings and quarterly meetings will be held and reciprocal visits between the HMCG / NPAS Ops Centres will be arranged. AACE will work with partners in police, fire and rescue, and search and rescue and the matter of concern will be discussed at the UKSAR Communications working group. The Medical Advisor to NARU is aware of the concerns and is looking to ensure learning from this tragic incident takes place. The RNLI is updating its page on the government's "ResilienceDirect" platform with details about its capabilities and pulling together material to be shared directly with emergency services partners. The RNLI will also work with the Coastguard to participate in partner awareness 'open day' events.

Noted (AI summary) The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work.

Noted (AI summary) Dorset Police are launching Project Synergy to improve their investigative operating model and increase the resilience and wellbeing of investigative teams. They are recruiting a Detective Chief Superintendent to lead the project, which includes forming investigative hubs and introducing investigation support officers. The Ministry of Justice acknowledges the coroner's recommendations and highlights existing and planned government actions related to funding victim support services, improving SARC provisions, and implementing the Victims and Prisoners Bill. Response notes Chief Constable will address concerns about rape investigation caseload. Network Rail has instructed the raising of the parapet at Menacuddle Hill/North Street Bridge to a minimum of 1250mm above adjacent surface level, with an additional course of stonework from an existing minimum height of 990mm. The current timescale for completion of the project is one year from instruction. Cornwall Council acknowledges the complexity of funding for sexual violence recovery services and states that there is no record of Ms. Dolamore having contact with the Council's children's or adult social care services. It describes the Early Help Hub and training offered to professionals.

Noted (AI summary) The practice discussed the case at a partners meeting and raised a significant event to discuss with the wider team, but concluded that no further action could be taken because the patient did not complete the advised tests.

Noted (AI summary) The Department for Levelling Up, Housing and Communities acknowledges the concerns regarding fire safety measures in extra care facilities and outlines existing regulations, guidance, and the role of the Building Safety Regulator. They have forwarded the letter to the Director of Building Safety at the Building Safety Regulator.

Noted (AI summary) NHS England acknowledges the concerns raised regarding the lack of automatic flags for non-responders to cervical screening in GP systems, clarifies the routine invitation process, and highlights ongoing work to improve screening uptake. TPP confirms that SystmOne has an automatic alert for cervical smears, irrespective of whether a patient has had one, but GPs are not informed when patients don't respond to invitations and that alert is not in the system. EMIS expresses condolences and states that their system already meets the recommendation of including an automatic flag/alert when a patient fails to attend for cervical screening as part of the National Screening Programme. They state that the System has an alert reading “Cervical Smear due or outstanding” that displays each time the patient’s record is opened, and also that GP practices can extract lists of patients who remain eligible but are not up to date with their cervical screening. The Department of Health and Social Care acknowledges concerns about patient record systems and alerts for non-responders for smear tests and states NHS England is creating a new IT Cervical Screening Management System (CSMS), due to go live in Quarter 1 2024/25, that will allow GPs to review a list of their non-responders.