Suicide

Action Planned (AI summary) EI, APEA, and PELG state that they will continue to review publications and update them where applicable. Additional work to develop a best practice guide for unmanned petrol filling stations is being undertaken by industry with the support of PELG. HSE notes that Tesco and the Energy Institute on behalf of PELG have carried out detailed reviews of their systems and guidance which they believe now address the issues raised by this incident.

Action Planned (AI summary) HMPPS has finalised Barricade Guidance, which will be issued to all approved premises staff on 1st August 2025, with staff required to acknowledge receipt by the end of September 2025. A new digital referral process is in place to pull information from prison and probation systems, and Oasys is used by Probation Practitioners to assess risk.

Action Planned (AI summary) The Ministry is working to deliver the Renters (Reform) Bill which will abolish section 21 evictions, is increasing funding for homelessness services and is chairing an Inter-Ministerial Group focused on developing a long-term strategy to get back on track to ending homelessness. It is also delivering 1.5 million new homes and administering the Local Authority Housing Fund.

Action Planned (AI summary) Unite Students is reviewing procedures for dealing with calls made to the ECC to effectively triage calls received and ensure appropriate questions are asked to understand the seriousness of enquiries. Welfare checks now escalate to the emergency services immediately if staff can't enter a room, and staff are trained in mental health awareness.

Action Planned (AI summary) National Highways will repair the boundary fence at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure. They are also in discussion to establish if it is feasible to maintain a more remote access to the electrical cabinets and remove the ladder from the retaining wall.

Action Planned (AI summary) Pending IT integration, the surgery will implement temporary measures recommended by the ICB, alongside other Surrey practices, and continue timely verbal and email communication with GPiMHS when concerns arise. The practice has already contacted the ICB and raised awareness with staff. By mid-April, Surrey Care Record will implement a live feed from the GP system to show the entire consultation free text, including historic consultations, to health professionals treating the patient.

Action Planned (AI summary) West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.

Action Planned (AI summary) Humber Teaching NHS Foundation Trust is implementing a new electronic record keeping system with a risk review form for the duty team to capture call information, and is establishing 'safety huddles' for staff to raise concerns.

Action Planned (AI summary) NHS England highlights national work on moving away from risk stratification and supporting personalised safety planning, and that NHS Sussex ICB is seeking updates from the Trust on actions including raising staff awareness of care plan and therapeutic observation importance, care plan audits, and developing a training package on the needs/risks associated with care experienced individuals. Sussex Partnership NHS Foundation Trust provided the coroner with a copy of the Ligature Anchor Point Risk Reduction Policy and a Patient Safety Briefing, launched refreshed ligature risk, assessment and awareness training in July 2024 (becoming mandatory in April 2025), completed installation of new anti-ligature alarmed bedroom doors on Rowan Ward, and commenced work on Maple Ward.

Action Planned (AI summary) Nottinghamshire Police is revising its policy to ensure consistent procedures for supporting suspects of relevant offences, irrespective of whether they are arrested or attend voluntarily. The revised policy will include an automatic referral to Liaison and Diversion (healthcare services) and is planned for implementation by 1st March 2025.

Action Planned (AI summary) NHS England will continue to support provider Trusts to deliver appropriate training and support to staff to deliver reasonable adjustments and accessible communication for patients. NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. The DHSC is rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism and NHS England is rolling out further training for staff working in mental health services to upskill staff in supporting autistic people in contact with those services.

Action Planned (AI summary) The Department notes the concerns about mental health bed availability and communication between teams. The Trust is implementing weekly MADE events to support discharge, maximising staff availability for crisis team referrals, and planning a transformation of urgent care pathways in 2025.