2021

Noted (AI summary) Suffolk County Council Highways has assessed the report and agreed to install a pair of hidden dip signs north of the Wallers Farm access, facing southbound traffic and will now proceed to design suitable locations, leading to the erection of new posts and signs in due course. National Highways states that they are not responsible for the A137 and cannot comment, advising the coroner to contact Suffolk County Council instead.

Noted (AI summary) The response expresses condolences and acknowledges the concerns regarding the impact of COVID-19 restrictions on healthcare delivery. It notes that general practice has been delivering services according to national Standard Operating Procedures, and provides a list of support services. Tameside and Glossop CCG acknowledges the concerns, explains the challenges faced during the pandemic, and states it will work with providers to optimise access times to mental health services. The Minister acknowledges the concerns raised and highlights existing NHS England guidance for general practices, including offering face-to-face appointments and managing mental health patients. It also mentions a consultation on new waiting time standards for community-based mental health services.

Noted (AI summary) The Minister acknowledges the concerns and outlines the responsibilities of CQC registered providers regarding staff training and care delivery. It also mentions NHS England support for care homes and the upcoming statutory inquiry into the Government’s response to the Covid-19 pandemic.

Noted (AI summary) NHS Brighton & Hove CCG, NHS East Sussex CCG, and NHS West Sussex CCG have reviewed preventable deaths messaging related to flammable products and are raising awareness of the risks from emollient creams, including publishing warnings and providing information to GPs, care homes, and patients about the fire risks associated with these products, based on previous alerts from the MHRA. The BMA acknowledges the concern about patient awareness of risks associated with emollient creams, but states they are not the appropriate organisation to address it. They suggest contacting the MHRA, NHS England, the Royal College of General Practitioners, and medical defence bodies instead.

Noted (AI summary) Staffordshire Police has commenced a criminal investigation into potential offences committed against Mrs. Dunn and is reviewing repeat cases of anti-social behaviour involving vulnerable people. They have also written to the Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board to understand if further information was known by partner agencies. Staffordshire Police provides an update that the case has been referred to the Independent Office for Police Conduct (IOPC) for an independent investigation.

Noted (AI summary) The response acknowledges the death and outlines current NICE guidance on managing large babies and gestational diabetes, noting an ongoing trial on inducing labour for predicted macrosomia.

Noted (AI summary) NHS England notes that the concerns raised relate to the design of medical devices and fall under the remit of the MHRA, but they have worked with the British Thoracic Society and continue to work with the Faculty for Intensive Care Medicine to develop guidance on alarm systems and breathing circuits. The MHRA states that the audible alarm system in the Philips Trilogy 202 device is based on an internationally recognised standard and that there is currently no evidence to indicate a wider safety concern. They are engaging with professional organizations to explore alarm prioritisation and have requested information from a patient safety incident database.