Railway related deaths

Action Planned (AI summary) • The Trust is developing a new private care protocol to guide clinicians on how to approach circumstances when a patient is accessing care from a private healthcare provider. • The protocol will operate within the existing policy framework, linked to existing policies and procedures for information sharing and record keeping. • Work to develop this new protocol is underway and will be completed by the end of this month, applying to new and existing patients.

Action Planned (AI summary) Google makes available an Inactive Account Manager tool, which allows users to designate third parties to receive parts of their account data in the event of their death or inactivity and are engaging actively with Ofcom and the Department for Science, Innovation and Technology on issues regarding access to information relevant to an inquest.

Action Planned (AI summary) Network Rail has applied for planning permission to increase the height of the parapet on the viaduct and curve it inwards, installing a safety barrier. The design stage is underway and it is hoped the works can be completed by the end of the financial year, subject to planning permission.

Action Planned (AI summary) Transport for London (TfL) will trial new technologies this financial year to identify customers on the track, starting with the Docklands Light Railway, Central line, and Piccadilly line, and continue to focus on recommendations from the Formal Investigation into the incident. TfL will implement measures to ensure customer safety information relating to risks associated with intoxication is available at all times.

Action Planned (AI summary) The council plans to provide Independent Visitor volunteers with Mental Health First Aid Training where necessary, and to include a specific topic relating to suicide prevention and signs in the Induction Training programme.

Action Planned (AI summary) Lincolnshire County Council intends to review its AMHP policies to incorporate references to 'masking' and will discuss the coroner's concerns at the next AMHP Forum.

Action Planned (AI summary) The Trust highlights that all staff are trained in the use of PARIS. A business case is progressing to split Bronte Ward into two smaller single sex wards. It also describes work being done on a trust-wide approach to improving knowledge of trauma-informed care, including a co-produced statement of intent, harmonizing training, and creating a resource hub. The Department notes actions the GMMH Trust is taking, including participation in a sexual safety collaborative and improvements to trauma-informed care. They also mention national initiatives such as investments in mental health estate improvements, dormitory replacements, and new models of integrated community mental health care.

Action Planned (AI summary) The Department of Health and Social Care will collect data on ward perimeters and review the evidence base and patient and family feedback regarding national guidelines for perimeter fences and security in acute mental health unit outside areas. The Priory Hospital Woodbourne issued bulletins on record keeping and shift handovers, is installing software to enable daily data transfer from handover sheets to electronic records, excavated the Beech ward courtyard to eliminate banking adjacent to the fence, and upgraded the CCTV system to ensure full visibility.

Action Planned (AI summary) The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.

Action Planned (AI summary) Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind a parapet wall and will close off gaps at either end of the new fence, with work expected to commence the week of March 7, 2022 and be completed within two weeks.