Other related deaths

Noted (AI summary) The Department of Health and Social Care acknowledges concerns regarding the use of Nearest Relative powers under the Mental Health Act. The response notes the Responsible Clinician's powers to bar requests for discharge and states the government does not intend to amend the Nearest Relative powers.

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. 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 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. 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. 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. 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) National Trading Standards states that they are unable to act on the issues raised, as product safety does not fall within their remit. They recommend the report be sent to the Office for Product Safety and Standards. The GMC asserts that medical training in the UK equips doctors with the necessary skills to assess complex acute situations, and no further specific training intervention is required for Immersion Pulmonary Oedema at this stage. They describe their role in quality assuring medical education.

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.