Product related deaths

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.

Noted (AI summary) The Department acknowledges concerns about the availability of suicide methods online and outlines actions to reduce suicide rates through the Suicide Prevention Strategy for England, including reducing access to the means of suicide and working with online retailers of harmful substances.

Noted (AI summary) East London NHS Foundation Trust clarifies that responsibility for environmental risk assessments following the patient's discharge from hospital would lie with the Reablement Team, which falls within the remit of the London Borough of Tower Hamlets. However, they will discuss the case within their regular team meetings. East End Homes states that the smoke alarms were of an appropriate standard, properly installed, maintained, and operated when activated. They believe that residents do not expect domestic alarms to be monitored externally, and they offer general guidance on fire safety. The GP practice will ensure the multi-disciplinary team and Social Services are made aware of concerns raised about the adequacy or safety of a patient's home environment. Clinicians can prompt the Care Navigator or Social Worker at the monthly Integrated Care Multidisciplinary Meeting to ensure that appropriate fire safety checks are implemented.

Noted (AI summary) The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated to relevant parties. Legal advice has been sought and guidance circulated to staff regarding potentially dangerous packages. Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do not intend to take any action in response to the report. The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders. The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online retail platforms and noting eBay's global prohibition of the sale of the chemical. It also notes work with the media to improve suicide reporting and the publication of an Online Harms White Paper. The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions within 24 hours.