2021

Noted (AI summary) Maidstone Hospital has implemented an action plan, recorded in their incident reporting system (DATIX), and taken steps to strengthen multi-professional working with Kent and Medway Social Care Partnership Trust. They have also commissioned an audit into consent and capacity practices and appointed a new clinical advisor and practitioner for capacity. Kent and Medway NHS and Social Care Partnership Trust have improved joint working with Maidstone and Tunbridge Well NHS trust, strengthened Mental Capacity Assessment monitoring, closely monitored Mental Capacity Act training and signed a Service level agreement with MTW to support patients detained under the Mental Health Act. The DWP outlines its procedures for vulnerable claimants, including reasonable adjustments for those unable to attend in person. They state that they are satisfied that appropriate support is available and do not propose to take any specific actions or make any changes at this time.

Noted (AI summary) The National Trust will conduct an immediate review of its risk assessment for Cock Marsh, including control measures and signage, and a signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures. There are plans for the Property Team to share this information Jordan's family and reviewing website visitor information. The Environment Agency acknowledges the coroner's concerns regarding safety measures at a specific site, but states that the National Trust, as landowner, holds primary responsibility for implementing measures like warning signs and rescue devices. The EA outlines its responsibilities as the navigation authority for the River Thames and its regular inspection of assets, but refers to case law indicating individuals should take responsibility for their own safety during potentially dangerous activities.

Noted (AI summary) The DHSC acknowledges concerns raised and outlines the roles of the CQC, NHS England, and NHS Digital in ensuring patient safety and appropriate training and supervision of healthcare staff, particularly Health Care Assistants, and refers to guidance on clinical risk management for health IT systems.

Noted (AI summary) Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of all active service user’s relevant information, and review of all service users at a face-to-face appointment. Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, regarding the transfer process. GMMH offers to meet with the coroner to discuss the transfer of services.