2022

Noted (AI summary) The Home Office, after consulting with the Department for Health and Social Care, believes that appropriate measures are already in place to reduce the risk of accidents involving liquid morphine and has no plans to introduce additional controls. NICE believes its existing guideline [NG46] on controlled drugs: safe use and management is sufficient, including recommendations for healthcare professionals to advise patients on safe storage and appropriate use. The MHRA will work with marketing authorisation holders to update product information for Oramorph, highlighting the need for secure storage and supervision after dilution.

Noted (AI summary) Connect Plus outlines enhanced measures being implemented, including drainage system cleaning, gully cleaning frequency increases, and safety barrier upgrades. They will also deliver a comprehensive plan for risk management including a cost benefit analysis, a review of carriageway resurfacing, investigation of illuminated warning signs, and a verge review. The Department for Transport acknowledges the concerns and notes that National Highways is responsible for the safe management of the Strategic Road Network and is taking actions to reduce risks of future collisions. DfT officials will continue to work with National Highways on the points raised. National Highways has installed a vehicle restraint system at the location of the fatal collision. They have also commissioned an independent review of the drainage system and are considering the viability of reprofiling the carriageway.

Noted (AI summary) Health Education and Improvement Wales (HEIW) describes the healthcare education commissioning cycle which aims to ensure high-quality education, training, and support for preregistration nursing students. They state that Multifactorial Risk Assessment education and training during their pre-registration education is not appropriate.

Noted (AI summary) TRL describes its role in supporting the SHARP helmet rating scheme and summarises existing research on helmet loss, concluding that more work should be done in light of changing motorcycle user demographics. They raise questions about the specific helmet and circumstances of the incident. The Department provides advice and guidance to motorcyclists through its Safety Helmet Assessment and Rating Programme (SHARP), including guidance on helmet selection and fitting on the SHARP website. DVSA's CBT syllabus includes helmet fitting and fastening, and examiners check helmet fastening. The Department will continue to review technical standards for helmets and promote helmet fitting and usage. The Forensic Collision Investigator provides information on the helmet involved in the incident and refers some queries to other agencies, stating the helmet met basic UK standards. They are unable to comment on how tightly the helmet was fastened when worn.

Noted (AI summary) TPP explains how the SystmOne electronic patient record system tracks amendments to consultations, stating that users are informed when an amendment has been made, by whom, and when, and that the audit trail is readily accessible. HMPPS has implemented a training program on medical emergency procedures for staff, including the use of emergency codes and cell entry protocols. A joint training event with healthcare staff was also held to improve care for acutely unwell prisoners, and weekly safety intervention meetings were introduced. The Trust has implemented compliance audit plans for NEWS2, is undertaking joint training with the prison service on several topics, and holds daily handover meetings to discuss prisoner clinical issues.

Noted (AI summary) The response outlines the current process for GPs to contact mental health teams, defends its appropriateness, and states that a review by a consultant psychiatrist was not clinically indicated in this case. It also mentions an independent review of the care provided will be shared with the family.

Noted (AI summary) Amazon includes a warning on e-scooter product pages stating they are prohibited on public roads in the UK, makes the warning prominent with bold font and a link to government guidance, sends communications to selling partners to remove references to public road use, and publishes education for selling partners on local legal restrictions. Escooterclinic attributes the incident to reckless user behavior, not the vehicle itself. They advise legalizing scooters with regulations and compulsory protective gear/insurance, citing confusion caused by legal rental scooters. Selfridges ensures there are clearly visible messages in stores and on their website stating that e-scooters may not be lawfully ridden on public highways. The legal team has issued reminders to stores and digital teams regarding this matter and are exploring system-based solutions for safety advisory requirements. Halfords advises potential buyers about the legal restrictions on e-scooter use at all stages of the sales process, both in-store and online, using prominent signage, legal statements on price tickets and warranties, and colleague training. They are also pushing for regulation in any Transport Bill. The MPS has published information on the MPS public website regarding the illegality of e-scooters, provides a flowchart to officers on how to deal with illegal e-scooter use and sends letters to e-scooter retailers asking them to display prominent signs about the legality of e-scooters. The MPS disputes that there is a correlation between legal enforcement of e-scooters and number of deaths and states that policy regarding head protection for licensed e-scooters was a decision made by the Department for Transport and Transport for London. Harrods is preparing notices for display in the Technology department and on their website, clarifying the illegality of e-scooter use on public roads. They also recommend helmets to customers and are implementing age verification checks. TfL highlights safety measures in the e-scooter rental trials, including speed limits, always-on lights, and minimum wheel size. They also promote safety guidance and have worked with the MPS to raise awareness of the law regarding private e-scooters. Onboards displays helmets with scooters, offers helmet discounts, encourages helmet use in-store, and features helmeted riders in online media. They display a sign about the illegality of private e-scooter use, include a disclaimer on invoices and website footer, and do not sell scooters to under-18s. The DVSA has been conducting market surveillance and has sent warning letters to retailers selling e-scooters without proper warnings about illegal use on public land. The government encourages helmet use for e-scooter trials and will consult on helmet wearing for future regulation. Evolve Skateboards is reviewing safety and legal compliance globally, including the UK, with expected rollout by June 2023. They are also a founding member of a PMD safety group advising the Land Transport Safety and Regulation Bureau in Queensland, Australia.

Noted (AI summary) Durham County Council refers to its written submission to the inquest and reaffirms its commitment to suicide prevention, but provides no new information.

Noted (AI summary) The Home Office acknowledges the coroner's concerns and outlines the government's commitment to providing resources to the police, including increasing officer numbers and funding for Devon and Cornwall Police. They also mention plans to introduce a new police funding formula. Devon and Cornwall Police detailed actions taken to address staffing and workload challenges in their CMCUs, including improvements in demand response times, implementation of wellbeing initiatives for personnel, and a process for recording and implementing learning from each summer period.

Noted (AI summary) Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time and state that without new evidence, they would have no legal right to insist on a further visit.