2021

Noted (AI summary) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.

Noted (AI summary) The Department for Transport clarified that local authorities are responsible for hazard signage and highway maintenance, and that existing guidance is available but not mandatory.

Noted (AI summary) NHS England is integrating care with a focus on addressing inequalities and supporting vulnerable children and families, and will work to raise the profile and uptake of the Healthy Start programme which is in the process of transferring from paper vouchers to digital cards. The Department of Health and Social Care acknowledges the concerns, states that national data does not show a significant increase in diagnoses of iron deficiency anaemia, and outlines existing schemes such as the Healthy Child Programme and Healthy Start scheme aimed at promoting healthy diets. They do not plan to introduce new policies specifically targeting nutritional anaemia.

Noted (AI summary) Jigsaw Homes Tameside states that its technician checked for alternative exits before boarding the door and the tenant had keys to the rear door.

Noted (AI summary) Hellesdon Hospital has implemented a complete ban on plastic bags, improved communication to families and carers, and put safeguards in place to disrupt the passage of restricted items. The Department of Health and Social Care acknowledges the concerns, mentions actions taken by the Norfolk and Suffolk NHS Foundation Trust, points to a safety alert published in 2011, and outlines progress in reducing suicides.

Noted (AI summary) NICE states they have a Clinical Knowledge Summary on gastroenteritis, which they believe gives appropriate advice, and that no action is required of them.

Noted (AI summary) Milton Keynes University Hospital outlined actions taken, including managing involved individuals, sharing resources, implementing the Association of Anaesthetists Quick Reference Handbook, and standardising monitor configuration across theatres. They are also working to improve teamwork, communication, and safety culture across multidisciplinary teams. The Royal College of Anaesthetists (RCoA), in collaboration with the Association of Anaesthetists and the Difficult Airway Society (DAS), will address issues through a coordinated campaign to disseminate and embed lessons learned into practice, including developing resources for multidisciplinary team training, working with stakeholders to highlight human factors, and spreading key messages through journals, newsletters, social media, and educational events. The Department of Health expresses condolences and notes actions taken by Milton Keynes University Hospital NHS Foundation Trust and the Royal College of Anaesthetists. They highlight national initiatives such as simulation-based training and equipment standards, but describe no specific new actions. They have brought the report to the attention of the CQC and HSIB. The Royal College of Anaesthetists (RCoA), the Association of Anaesthetists and the Difficult Airway Society launched a coordinated campaign including a dedicated webpage, educational talks, articles in members' magazines, and social media promotion to disseminate learning points from the case. They will develop more resources for multidisciplinary team training and maintain work to prevent unrecognised oesophageal intubation through the Safe Anaesthesia Liaison Group.

Noted (AI summary) Stockport Clinical Commissioning Group states that face-to-face GP consultations are available where clinically appropriate or requested. They have re-circulated information sheets detailing referral options to GP practices and delivered presentations on suicide prevention. The practice involved in the case has completed a reflection exercise. NHS England acknowledges concerns about telephone consultations and referral guidance, referencing existing national guidance on safety netting. They note the local CCG has provided a separate response detailing relevant information and steps taken, and do not propose responding further on a national level.

Noted (AI summary) The Department for BEIS acknowledges the report but asserts that existing product safety regulations are adequate for mobility scooters. They argue that placing an obligation on individuals to undertake an assessment before purchasing specific products would be disproportionate and propose that no further action is taken.

Noted (AI summary) The Department for Levelling Up, Housing & Communities references existing building regulations, guidance, and the role of fire and rescue authorities, but does not commit to further action.

Noted (AI summary) NHS England and NHS Improvement references existing guidance for telephone consultations, safety measures, and pain management of fractures; they indicate learning from the death will be shared. The Department of Health and Social Care acknowledges concerns raised, explains changes to general practice during the pandemic, and highlights existing NICE guidance and resources for remote consultations.

Noted (AI summary) Greater Manchester Health and Social Care Partnership will present learning from the case to the Greater Manchester Quality Board, communicate advice and guidance to relevant providers, and share learning through governance and learning forums. NHS England expresses condolences, acknowledges the concerns, and highlights national guidance and resources for wound care and remote consultations, including the National Wound Care Strategy Programme.