Product related deaths

Noted (AI summary) The Department of Transport refers to existing published guidance for users of e-cycles and e-scooters on battery safety, and states that pending the outcome of further research, no additional action is appropriate at this stage. The West of England Combined Authority states that specific actions to address the concerns raised by the Coroner do not lie within its strategic functions, requiring national government action in the first instance. They believe their provision of on-street rental e-scooters, e-bikes, and e-cargo bikes reduces the number of privately owned vehicles kept at home. OPSS has undertaken a program of work including commissioning research, engaging with gig economy firms to share safety information, and working with other government departments to publish guidance on e-bike and e-scooter safety. A new safety campaign with consumer messaging is expected to launch in the autumn.

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 TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support Tool with the support of NFCC and LFB, but anticipate it will not be available until 2024. The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future deaths in relation to these services. The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated Adult Social Care Digital Skills Framework to support the development of digital skills across the adult social care workforce. The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003. The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors like being bed-bound and a smoker; a table detailing planned actions and timelines is attached. The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems to smoke alarms during fire safety checks.

Noted (AI summary) Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of all active service user’s relevant information, and review of all service users at a face-to-face appointment. Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, regarding the transfer process. GMMH offers to meet with the coroner to discuss the transfer of services.