2015

Noted (AI summary) The HSE states it has no enforcement powers under the General Product Safety Regulations regarding showerheads and has passed the coroner's letter to the local Trading Standards Department. The council explains its duties under the Consumer Protection Act and General Product Safety Regulations, noting the absence of specific regulations for showerheads. They suggest the HSE review guidance regarding Legionnaires' disease and shower systems.

Noted (AI summary) The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the patient's notes as evidence.

Noted (AI summary) The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing bed provision in Cornwall. NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. They are also reviewing provision for individuals placed out of county to inform future commissioning.

Noted (AI summary) Manchester Mental Health and Social Care Trust (MMHSCT) has agreed to provide UHSM with advice in respect of their development of a self-harm policy and guidance. Regular liaison meetings will be established between UHSM, MMHSCT and GMW. The Department of Health acknowledges the concerns raised and outlines several existing initiatives related to mental health and self-harm prevention, including national indicators, research funding, and the Mental Health Action Plan.

Noted (AI summary) Serco states that they were the healthcare provider at HMP Norwich at the time of the death but no longer provide any services there and thus cannot implement the recommendations. They note that the report has been sent to HMP Norwich and Virgin Care. HMP Norwich acknowledges the coroner's concerns regarding CPR training, outlines the current legislation and risk assessment process for first aid needs, and states that there is no requirement to provide AEDs or defibrillator training. They highlight the presence of a healthcare team providing 24-hour cover. Virgin Care, the current healthcare provider at HMP Norwich, has instituted changes to its procedures, including a local induction process and checklist, and guidance for resuscitation in a joint protocol with HM Prison Service. These were put in place by March 31, 2015.