Suicide

Action Planned (AI summary) The Civil Aviation Authority will instruct inspectors to encourage operators and Approved Training Organisations to improve mental health support to pilots, including upskilling peer supporters and supporting escalation of concerns to mental health professionals, and is reviewing its Pilot Health Safety Sense Leaflet.

Action Planned (AI summary) Swansea Bay University Health Board acknowledges concerns about treating individuals with both addiction and mental health diagnoses. They are developing a Standard Operating Procedure (SOP) and care pathway to address this, starting meetings in May 2025 to review practices and integrate mental health and substance use services.

Action Planned (AI summary) The MPS is reviewing its corporate process for s.135 warrants and will incorporate the matters raised in the PFD report and learning identified into this review. HMCTS has reiterated arrangements for applications to magistrates’ courts in London and held a meeting with NHS colleagues to explore concerns, committing to continued communication and partnership working.

Action Planned (AI summary) The MPS corporate process for s.135 warrants is being reviewed, and the PFD report's matters and learning will be incorporated into this review. HMCTS has reiterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. They also arranged a meeting with NHS professionals to explore concerns.

Action Planned (AI summary) Hertfordshire and West Essex ICB notes long waiting times for ASD assessments and outlines actions including pathway investment, implementing a service model redesign, providing additional funding, and creating resource packs for parents and carers. NHS England published the National Framework and Operational Guidance for Autism Assessment Services in April 2023, setting out expectations for integrated autism assessment pathways and that referrers must not omit providing assessment or intervention for health-related needs. The council erected notices signposting to the Samaritans immediately after the death and will assess the feasibility of raising or replacing bridge parapets with new, higher versions once a Principal Inspection is complete, after liaising with Network Rail to undertake the Principal Inspection at the first opportunity.

Action Planned (AI summary) Mid South Essex NHS Trust is working with partners to develop clear and straightforward pathways for mental health care in the Emergency Department, with a rollout programme and training planned for ED staff after final approvals. EPUT reports that the Mental Health Liaison team now has access to all key systems including SystmOne, and the Inpatient and Urgent Care Divisional Directors of Quality and Safety are establishing regular quality forums with Directors of Nursing in Acute hospitals.

Action Planned (AI summary) The Royal College of Psychiatrists will communicate risks and best practices regarding cross-titration to its members through newsletters and other communications, raise the issue with mental health organizations, and use the PFD to inform their priorities. It also advocates for more research on the use of video technology in observing patients, and has worked with NHS England to publish principles for trusts considering this technology.

Action Planned (AI summary) NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.