Suicide

Action Planned (AI summary) NHS England states that the Department of Health and Social Care committed to engage with stakeholders to understand how the current legal framework is applied in ED settings and identify solutions to the problems raised. NHS England is tasking local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. The HSSIB notes the concerns raised and states that two investigations have been launched: one exploring the care of patients in mental health crisis in emergency departments (launching October 2025), and another exploring ambulance service response to patients in mental health crisis (launching Spring 2026).

Action Planned (AI summary) Network Rail is developing industry guidance on welfare communications and has set up an Industry Working Group on Welfare Communication. The SWR investigation report was considered at the NR SPAD Recommendations and Review Panel.

Action Planned (AI summary) The Trust has updated its data insights visualisation platform to capture all essential data, improved its Triangle of Care initiative, and offers the Triangle of Care training and Esther coaching to agency colleagues. The Trust has embedded carer engagement across all teams, including those supported by long-term agency staff. The Trust is considering ways to better support agency staff in risk management training, and commissioned an independent audit to review the adequacy of the Trust’s arrangements for involving families and carers.

Action Planned (AI summary) The Health Board supports broader access to patient medical records and has commenced work to broaden access to clinicians, including CRHTT, via the Welsh Clinical Portal. They are also working to allow patients fuller access to GP information via the NHS App.

Action Planned (AI summary) The NPCC highlights the importance of personal responsibility on license holders for the security of firearms. The NPCC commenced delivery of an additional two-day course for Firearms Licensing Enquiry Officers focusing on domestic abuse, family turmoil, mental health and wellbeing in June 2025. The Home Office alerted all police forces to the issue of information sharing regarding shotgun license holders, and it is possible for police to check if an individual is a firearm or shotgun certificate holder. They will also engage with the DHSC directly regarding police access to health information. The Department will explore broadening access to relevant medical information of others residing at licence-holders' addresses and engage with GP representatives. They will work with them to ensure that operational guidance relating to the existing Digital Firearms Marker policy remains fit for purpose and considers ongoing learnings.

Action Planned (AI summary) NHS England is developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems, to ensure all required information is available to staff. It highlights existing systems, including the National Care Records Service, and discusses reports received by the Regulation 28 Working Group.

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) NHS GM will produce an advice briefing for GPs and practices to be distributed through primary care networks, reminding them of responsibilities around mental health patients, mode of appointments, family involvement, and sharing information, including a decision-making tree flowchart.