Other related deaths

Action Planned (AI summary) The College of Policing will update APP (Authorised Professional Practice) within three months to clarify that disclosure of information about a person who poses a risk of harm can be made to parents and/or carers of children. The MPS is reviewing its MAPPA processes, including scoping the feasibility of introducing a Potentially Dangerous Person (PDP) process as outlined by the College of Policing’s APP Guidance; the outcome of this review is anticipated within six months. The Home Office is considering options for better management of domestic abuse offenders, including a domestic abuse 'register', and is working to improve information and data sharing between agencies for safeguarding children, with a report due before Parliament in Summer 2023. The Department is updating resources for health visitors and school nurses, emphasizing assessments of family relationships and chronology of events for children with additional needs, due to be published shortly. They have also agreed to a cross-government programme of work focusing on strengthening whole family approaches and improving evidence.

Action Planned (AI summary) NHS Devon ICB has asked commissioned services to review and update safeguarding policies, disseminated a learning brief to healthcare providers, and will present the learning from this case to safeguarding adult partnerships.

Action Planned (AI summary) The Trusts have jointly developed a proforma letter to be given to patients when their care is transferred, containing key contact details and copied to the patient's GP and the receiving Clinical Nurse Specialist. The firewall issue between the Trusts has been resolved and electronic data connections are visible. The Trusts have jointly developed a proforma letter to be given to patients when their care is transferred, containing key contact details and copied to the patient's GP and the receiving Clinical Nurse Specialist. The firewall issue has been resolved.

Action Planned (AI summary) Tower Bridge Care Home describes arrangements for diabetic foot clinic attendance, communication with GPs and multidisciplinary meetings, and identifies residents with high needs to the consultant geriatrician for face-to-face reviews, since September 2022. They also describe processes for DNAR (Do Not Attempt Resuscitation) orders and managing capacity issues. The RCGP is working to improve communication between secondary and primary care with colleagues across specialities, and with NHS England and NHS Improvement to improve communication links. King's College Hospital has established a working group to improve consent and MCA assessments, reviewing consent and MCA training programmes, and updated the Trust's consent policy. The Trust also initiated a Trust-wide consent audit in September 2022.

Action Planned (AI summary) The ICB has established a task and finish group to review the clinical pathway for management of Hyperglycaemia in Care Homes. The ICB plans to trial new rapid acting insulin guidance, review the existing insulin authorisation form, and support the development of a business case to expand the use of continuous glucose monitors devices for patients in care homes.

Action Planned (AI summary) The government has allocated £150 million of additional system funding for ambulance service pressures in 2022/23 and has tendered a procurement contract for auxiliary ambulance services. Local health and social care partners are using additional action to support discharge and improve patient flow and £450 million was invested to upgrade A&E facilities in 2020/21. NHS England issued a national letter in February 2022 emphasizing the need to address harm caused by handover delays, followed by meetings with systems to develop plans. Avoidable conveyance rates to Emergency Departments have decreased. All Reports to Prevent Future Deaths are discussed by a working group to share learnings and insights. NHS Birmingham and Solihull are implementing several initiatives to improve patient flow, including the development of virtual wards to facilitate early discharge and admission avoidance, with a target of 340 virtual ward beds by April 2024. They are also holding daily meetings to review mental health attendances and admissions, and opened an All Age Urgent Care mental health centre.

Action Planned (AI summary) Planning and Housing Cornwall Council is expediting the application for tree works, including internal consultations, with a decision expected before the end of the month; they have also scheduled a meeting for consultation. Sailors Creek CIC hand-delivered letters, posted safety notices, removed mooring ropes from trees, held a site meeting with concerned parties, and adapted their risk assessment and safety brief. They have also implemented a temporary system for positioning moored boats further into the creek, and plan to replant trees and develop a tree management plan by the end of September 2022, and complete the mooring chain along the length of the beach by the end of 2022.

Action Planned (AI summary) The LFB plans to conduct a regulatory audit of the premises, issue a clarification of LFB policy on vetting of fire safety audits, conduct a full review of training material for vulnerable sleeping risk premises and develop refreshed CPD, apply the new national scheme for third-party accreditation of fire safety inspecting officers, review guidance on portable electric fan heaters, highlight the issue to housing providers, and continue to press for guidance on fitting of digital keypads. The NFCC will report the coroner's concerns to BSI committees (FSH12 and FSH14) to encourage debate and petition for positive outcomes, and will continue to work with the Home Office to ensure the matter of Concern is suitably addressed in any Guidance revision. Sequence Care has revised its competency checklist, re-assessed staff against it, arranged additional training sessions and updated fire alarms in homes to link to an Alarm Receiving Centre (ARC); ARC links at two homes will be completed by 24 June 2022. BSI's committee FSH/12 will pass on concerns to technical committee FSH/14 and sub-committee FSH/12/1, who will consider the issues and update progress in due course; the sub-committee FSH/12/4 may consider the issue of electronic locking as part of a forthcoming amendment to BS 7273-4.