2021

Noted (AI summary) The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a protocol to address placing people outside of the Trust’s geographical area. CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that the CQC will participate in a 'learning event' with the local authority and Devon Partnership Trust. The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement and participation of the family.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured medication reviews in primary care. The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request information from DHSC and NHS-E&I regarding patient safety incidents.

Noted (AI summary) The Metropolitan Police Service will develop additional training on recording property, especially regarding risk, and implement it in the "Street Duties" course for probationer constables. The officer involved in the incident has been spoken to and advised on recording property and circumstances for seizure. The Trust has discussed the concerns with Borough Lead Nurses and sent letters to nursing staff, highlighting expectations for patient searches, observations, and rapid tranquilisation monitoring. The Trust now requires formal training and competency assessment for staff conducting searches and observations, with Registered Nurses exclusively performing RT monitoring within eyesight for the first hour post-administration. The Department acknowledges the concerns and outlines actions taken by the East London NHS Foundation Trust (ELFT), NHS England and NHS Improvement (NHSE & NHSI), and the Care Quality Commission (CQC). It highlights ongoing monitoring and planned inspections of ELFT.

Noted (AI summary) Wakefield Council is undertaking physical works, including building robust barriers and installing a safe viewing platform at Kirkthorpe Weir, expected to be completed in mid-July 2021. They are also linking still water body health and safety policies to flowing water areas. Foresight Group states it is the investment advisor to Yorkshire Hydropower Limited (YHL), and does not exercise control over YHL's affairs, so YHL are taking steps to ensure there is no repetition of this tragic accident. Foresight endorses the proposed security measures outlined by YHL, which include additional fencing, warning signs, enhanced CCTV, improved PA system, barriers, covering channels, ongoing liaison with emergency services, and daily manned security presence during summer months. Yorkshire Hydropower Limited has undertaken a detailed review of trespasser routes and plans to improve signage, install additional CCTV cameras with remote monitoring, and engage with the local community and police to deter further trespass. The Canal & River Trust's national Education team produced a Schools Water Safety Awareness Communication and a water safety video aimed at children aged 5-11 years which focuses on the Trust's ‘Stay Away From the Edge’ campaign.

Noted (AI summary) The Christian Congregation of Jehovah's Witnesses asserts that while they provide support to vulnerable adults, they do not formally bring them into their care, thus a formal policy is deemed unnecessary; they rely on Christian duty and scriptural guidance.

Noted (AI summary) The Department acknowledges the concerns and outlines national initiatives to improve mental health services and suicide prevention, including investments in community mental health care and digital information sharing. It notes local action by the Stockport CCG and offers condolences to the family.

Noted (AI summary) Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England. Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage starting CPR unless irreversible death is certain. They have shared the response with relevant bodies.