2021

Noted (AI summary) The Trust has taken steps to reduce risk from ligatures, including installing pressure sensor alarms on en-suite bathroom doors, removing door furniture, and establishing a rolling capital programme for ligature works. They are also reviewing therapeutic observational practice, staffing levels, and care plans. HSE states that the safety of the environment for patients, including management of ligature points, falls within the remit of CQC, not HSE, according to a Memorandum of Understanding. NHS Birmingham and Solihull ICB provides supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report. The CQC has asked for weekly reports on ward improvements, sought an independent review from NHS England, and will share learning from the inquest with inspectors and registered persons. They are monitoring the trust and will use enforcement powers if regulations are not met.

Noted (AI summary) The Home Office acknowledges the concerns and outlines the police powers to deal with illegal raves, but states that decisions about deployment are operational matters for the police. They highlight funding to tackle drug supply, treatment services, and Project ADDER.

Noted (AI summary) England Boxing had already implemented remedial actions to increase safety and awareness, including revising the Rule Book to make safeguarding responsibilities clear, introducing mandatory DBS checks, and implementing safeguarding training. Following the inquest, they are setting up an independent inquiry to investigate adherence to regulations. DCMS acknowledges the concerns, describes existing safeguarding measures and engagement with sports bodies, but states they do not intend to introduce further sport-specific legislation at this time. They will work with Sport England and England Boxing to review the specific concerns raised.