Other related deaths

Noted (AI summary) The RFU cascaded the findings in the Regulation 28 Report to all clubs involved in the Premiership. The RFU also raised this subject at the June meeting of the Professional Game Board. The ECB intends to circulate communications to appropriate representatives, including a list of steps from the CAA, within one month and emphasize the need to share the information directly with players. All corporate travel for ECB employees and representatives must be booked through the ECB's travel management company Ventur. The EFL reissued guidance to all Clubs, which was received in March 2021. The EFL will reissue a link to the guidance in advance of each transfer window. The British Horseracing Authority briefed its Board and prepared a draft guidance note to send to its member bodies and engaged with the Civil Aviation Authority (CAA). The FA states they were not aware of the coroner's report until it was provided by the English Football League. The FA relayed CAA guidance on illegal flights to clubs and Registered Intermediaries in March 2021. The Department for Transport and the CAA are reviewing the powers available to them in investigating breaches of aviation regulations and what powers they would find of assistance in their investigative and enforcement role. The Jockey Club requires aircraft operating at its racecourses to obtain prior permission, demonstrate pilot licensing, provide aircraft registration and insurance, and confirm whether flights are private or commercial. The Jockey Club and Helicopter & Aviation Services Ltd provide records of aircraft activities to authorities when requested. The organisation circulated a note to its members recommending that they do not pay for or use unlicensed commercial flights, sharing the concerns of the Dorset Coroner. The Professional Footballers Association has written to its current members and put information on its website to raise awareness on the issue of unlicensed aircraft, and attached the guidance issued by the CAA. UK Athletics has distributed information regarding private flights to World Class Programme athletes, coaches, support staff, and known agents, emphasizing the need to check the legality of flights. The LTA sent a communication to relevant players on 9 August 2022 regarding commercial flights from unlicensed operators, including a link to CAA guidance. The Institute of Directors included a statement in its 'Influence' email to 20,000 members and posted a notice on its website warning of the dangers of unauthorised flights, following a request from the Civil Aviation Authority. The Premier League will send correspondence to the Legal, Club Secretarial, and Football departments at each of the Clubs. The Premier League met with Clubs at the Annual General Meeting on 9 June 2022 and raised the issue to the Chairs/Chief Executives/Owners attending. The Confederation of British Industry plans to publish an article on employee wellbeing and safety linking to the Sala case, use social media to amplify the importance of employee well-being and safety, and flag the case to its account managers who manage the CBI's aerospace members. The Rugby Football League wrote to all member clubs advising them of the situation regarding private flights and asking them to ensure they do not use such flights. The Department for Digital, Culture, Media and Sport shared CAA guidance with sports organisations, Live music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians' Union. UK Sport asserts that the use of illegal private plane journeys is not permitted with their funding and that the risk of government funded sports using them is minimal. The EFL circulated a CAA notice to club secretaries raising awareness of the risks of illegal public transport using unlicensed aircraft. The Executive Association of Great Britain stated that the report and concerns are not applicable to their particular circumstances as they do not arrange travel for members, and members do not travel by air to attend meetings. The British Chambers of Commerce circulated briefing materials to its Chamber of Commerce members, raised the issue in a call with Chamber of Commerce CEOs, and highlighted the importance of taking action at the BCC Board. The RFU requested Premiership clubs review the PFD report on commercial flight chartering and ensure flights are legal and have required authorisations, certifications and permissions, and pass the information to relevant employees. Motorsport UK will publish advice to its license holders on its website and in its monthly ezine regarding air-worthiness of chartered aircraft and pilot qualifications.

Noted (AI summary) Humankind has implemented a standard operating procedure for prescription deliveries, including mandatory witnessed delivery and recording in the service user's notes. They have also established a contact procedure and contingency plan for failed deliveries, and record failed deliveries as incidents in their management system. Boots UK acknowledges the concerns raised and states the gravitas is duly noted.

Noted (AI summary) The Secretary of State acknowledges concerns about including 'obesity' as an indicator of abuse and neglect in safeguarding guidance, highlighting existing guidance on safeguarding children's welfare and health. They note existing initiatives to improve access to services for children living with overweight or obesity and refer to the Independent Review of Children’s Social Care, stating that the concerns will be considered in the context of the review's recommendations.

Noted (AI summary) Barnet Homes will cooperate with fire risk assessments, engage with telecare reviews, and explore telecare funding. They will pursue a recommendation with the London Borough of Barnet for sheltered housing tenants to have a home fire safety visit and will carry out PCRAs on all its Sheltered Housing tenants with target date for completion of any missing PCRAs in Sheltered Housing is Monday 16th May 2022. Network Homes asserts that its fire safety management and systems exceed legal requirements and reflect best practice. They state the fire safety systems at Knightleas Court behaved as expected and the fire was contained. CQC acknowledges the concerns but states Knightleas Court is not a registered service. They are working with the National Fire Chief’s Council on promoting Person-Centred Fire Risk Assessments.

Noted (AI summary) The Welsh Government describes plans for an Expert Group to support a National Care Service for Wales and states that the Minister for Health and Social Services will write to Regional Partnership Boards, Health Boards and Directors of Social Services requesting a review of provision for older peoples residential care and robust exploration of sufficiency of provision. Gwynedd Council explains the challenges it faces in providing care placements, particularly due to COVID-19 and staffing capacity, but states that the link between the incident and placement availability is not entirely clear.

Noted (AI summary) UCAS provides context on how students can share information about support needs within their application and how universities then arrange support. They highlight that the information is optional and handled confidentially, and doesn't impact academic judgement.

Noted (AI summary) The British Diving Safety Group (BDSG) highlights its existing efforts to promote awareness of Immersion Pulmonary Oedema (IPO) through training materials, safety documentation, and collaboration with various organizations. They do not believe a 'fitness to dive' medical certificate is required. The UKDMC continues research into IPO and publish findings, educate medical referees via Google-group and conferences, provide information directly to diving organisations and articles are published on the UKDMC website and in magazines for divers, provide lectures at conferences for amateur divers, work with the British Diving Safety Group, spoken to the Royal College of Pathologists and provide guidance on fitness to dive. The new operators of the Diving Centre, Deep Training Services Limited (DTSL), are implementing a requirement for safety boat capability to be available during all diving activities to assist with diver removal from the water.

Noted (AI summary) Maidstone Hospital has implemented an action plan, recorded in their incident reporting system (DATIX), and taken steps to strengthen multi-professional working with Kent and Medway Social Care Partnership Trust. They have also commissioned an audit into consent and capacity practices and appointed a new clinical advisor and practitioner for capacity. Kent and Medway NHS and Social Care Partnership Trust have improved joint working with Maidstone and Tunbridge Well NHS trust, strengthened Mental Capacity Assessment monitoring, closely monitored Mental Capacity Act training and signed a Service level agreement with MTW to support patients detained under the Mental Health Act. The DWP outlines its procedures for vulnerable claimants, including reasonable adjustments for those unable to attend in person. They state that they are satisfied that appropriate support is available and do not propose to take any specific actions or make any changes at this time.

Noted (AI summary) The National Trust will conduct an immediate review of its risk assessment for Cock Marsh, including control measures and signage, and a signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures. There are plans for the Property Team to share this information Jordan's family and reviewing website visitor information. The Environment Agency acknowledges the coroner's concerns regarding safety measures at a specific site, but states that the National Trust, as landowner, holds primary responsibility for implementing measures like warning signs and rescue devices. The EA outlines its responsibilities as the navigation authority for the River Thames and its regular inspection of assets, but refers to case law indicating individuals should take responsibility for their own safety during potentially dangerous activities.