Other related deaths

Noted (AI summary) North West Ambulance Service has revised its 111 policy to remove exclusions for self-conveyance to hospital, save for Category 1 incidents, and to directly confirm patient refusal of an ambulance where possible. The updated SOP went live on 5th September 2023 and staff were informed. The Department for Levelling Up, Housing and Communities will pilot measures to improve enforcement of damp and mould with £10m funding and intends to introduce the Decent Homes Standard to the private rented sector. They will also introduce new regulations following a review of the Housing Health and Safety Rating System (HHSRS). The Department of Health and Social Care states that NHS England has confirmed with ambulance trusts that no blanket policies are in place advising patients with chest pain not to travel to A&E. NHS111 calls are dealt with on a case-by-case basis, and patients are provided with interim advice.

Noted (AI summary) NHS England are committed to moving to a ‘0-25 year service model’, offering person-centred and age-appropriate care for mental and physical health needs. A Patient Safety Bulletin was issued highlighting the need for ‘prompt measurement of ammonia and action in the event of hyperammonaemia’. The FSA expresses condolences and explains its responsibilities for food safety, noting that nutritional advice and labelling are the responsibility of the DHSC, to whom they will forward the report.

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 Culture, Media and Sport outlines actions planned following the Gambling Act Review, including enhanced affordability checks, strengthened protections for young adults, and empowering consumers to control their gambling, with the main measures expected to be in force by summer 2024. Flutter provides background information on the company and its brands, particularly Betfair, explaining the difference between the Sportsbook and the Exchange. The Gambling Commission outlines several initiatives and planned actions, including collaboration with stakeholders to improve understanding of gambling-related harm, support for research, and the development of GamProtect, a 'Single Customer View' solution for identifying customers at risk of harm.

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'.