2018

Noted (AI summary) The Department of Health and Social Care references NICE guidelines on intrapartum care and states NICE will log the coroner's concerns for future review but does not plan to update the guideline at this time.

Noted (AI summary) Human Race acknowledges the coroner's feedback regarding the tragic accident, but maintains that the events were not reasonably foreseeable. The company states it will take the comments on board when planning and risk assessing future events, but emphasizes the difficulty of anticipating all potential eventualities.

Noted (AI summary) The council states that they do not own the land in question, nor have any legal powers to build a wall or fence. They provide a map indicating ownership of the land adjacent to the pathway.

Noted (AI summary) NHS England explains its commissioning responsibilities and lack of jurisdiction over private healthcare providers. It states that it cannot breach patient confidentiality to share private consultation details with a patient's GP.

Noted (AI summary) Following concerns about mothers bed sharing with babies while breastfeeding, the Trust has reviewed concerns and taken further actions in addition to those identified in the Serious Incident Report. An action plan with supporting documentation details improvements regarding safe sleeping advice and documentation. This document appears to be an action plan related to the previous response, but it is not possible to summarise the actions without the context of the coroner's concerns.

Noted (AI summary) The Welsh Government will discuss the incident at the all Wales Serious Incidents Group in October to improve learning and develop/disseminate further guidance across professional groups. They will also keep the case under ongoing review. The University Health Board has implemented a safe system of work for recording items stored in patient PODS, disseminated risk management policies via ward meetings with staff sign-off, and is developing a standard list of documents for disclosure at inquest. NHS Improvement supported the MHRA by searching the National Reporting and Learning System, which reinforced the importance of annual eye screening for patients on long-term Hydroxychloroquine. They stand ready to support the MHRA in ensuring any future changes to monitoring reach healthcare professionals. The MHRA acknowledged the concerns and requested further information regarding the case to determine if regulatory action is required, including observed drug concentrations, symptoms of overdose, concomitant medications, post-mortem sample details, and renal/liver function test results. NHS England is working to ensure that by 2020/21, 280,000 more people with serious mental illness have their physical health needs met. NHS Improvement issued an Estates and Facilities Alert on 'Assessment of ligature points' on 19 September 2018.