Product related deaths

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 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. 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 organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003.

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.

Noted (AI summary) The Department for BEIS acknowledges the report but asserts that existing product safety regulations are adequate for mobility scooters. They argue that placing an obligation on individuals to undertake an assessment before purchasing specific products would be disproportionate and propose that no further action is taken.

Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.

Noted (AI summary) West Midlands Ambulance Service took immediate action by informing all frontline staff of requirements for medical gas cylinder assembly/disassembly and sharing lessons learned with partner organizations. The CQC acknowledges the concerns but states it is outside of their remit to issue or change formal guidance or policies around oxygen usage or safety, as they are not clinical experts. They will continue to communicate with WMAS and monitor actions taken to improve safety. HSE will support MHRA as the lead authority and will use its communication channels to promote any information/guidance produced by the MHRA. They will also consider if HSE guidance document INDG459 should be updated to reflect any new information/guidance produced. MHRA has commenced a dialogue with the Association of Anaesthetists and the Safe Anaesthesia Liaison Group of the Royal College of Anaesthetists to raise awareness of ignition within valve components of oxygen cylinders. MHRA was represented on a multiagency group which hopes to publish guidance once ratified by the Councils of both the RCoA and the AA.