2022

Noted (AI summary) The Royal College of Emergency Medicine states that provision of medical cover to police custodial units does not fall within its remit. The IOPC will not be undertaking an investigation but is satisfied that the reflective practice review process can be used effectively to prompt reflection and insight into this incident. The Metropolitan Police Service will implement the Reflective Practice Review Process (RPRP) for the officer in question, which will include an opportunity to reflect on the missed opportunity to offer an apology to Mr. Taylor's family; the officer's line manager will also identify any additional training needs. The Department of Health and Social Care outlines the process and considerations involved in allowing police officers to carry salbutamol inhalers, noting it would require a change in legislation, and would need to be initiated by the Home Office, after consulting the Commission on Human Medicines (CHM) and undertaking public consultation; it also highlights NHS England's focus on preventer inhalers and monitoring by GPs.

Noted (AI summary) The RCPCH acknowledges the concerns and will share the report with its Quality in Clinical Practice committee for further discussion to identify opportunities to prevent future deaths, and will continue to collaborate with the RCGP on safe and effective pathways of care for children and young people, ensuring the child health workforce is represented in national discussions on children’s urgent and emergency healthcare, and patient safety. NHS Digital reports that the 111 algorithm was modified and provides detail on the governance structure overseeing NHS Pathways, including independent oversight, consistency with NICE guidelines, and a process for reporting incidents and requesting changes. The RCGP acknowledges the concerns, outlines educational material for GPs in training, and welcomes changes to the 111 out-of-hours algorithm. They support investment in primary care infrastructure to improve data sharing, but note that dissemination of a rare case report is not currently considered necessary.

Noted (AI summary) Farnham Park GP Practice conducted a Serious Event Audit on 31 May 2022 and identified a clinical psychologist to provide mental health training. Unexpected deaths will be discussed at weekly clinical meetings. NHS England highlights existing educational resources and guidance for GPs and outlines planned future actions including the rollout of the Learn from Patient Safety Events (LFPSE) service and implementation of the Patient Safety Incident Response Framework (PSIRF), and sharing the report with Regional Mortality Boards. NHS Frimley ICB will share the coroner's concerns with GP practices, focusing on documentation of suicide/self-harm risk and mental health assessments. They will also update the local formulary to highlight national guidance on the increased risk of suicidal behavior when starting antidepressants, with a point-of-prescribing alert, to be completed by August 2022. CQC contacted Farnham Park Health Group and received evidence of a significant event analysis and action plan implemented in response to the death, with 7 of 10 actions already completed. They also raised the failure to notify CQC of the death with the provider and will consider further action. The GMC has reviewed the concerns and decided not to investigate further, but will share them with the doctor's responsible officer for discussion during their revalidation. The Department acknowledges the concerns and notes actions taken by other bodies, emphasizing the clinical responsibility of GPs in prescribing decisions and referencing NICE guidelines. It provides general context and reiterates existing guidelines without committing to specific new actions.

Noted (AI summary) Sheffield Health & Social Care NHS Foundation Trust outlines a plan to develop a protocol for working with older adults with a forensic history, ensure thorough risk assessments when removing a service user from detention, improve communication with service users and families, ensure complex clinical decisions are multidisciplinary, and deliver online training on the Mental Health Act. The Government Legal Department, on behalf of the Probation Service, acknowledges the concerns but states it's a matter for the sentencing Judge to determine Restriction Orders. They will obtain the Court transcript of Mrs Grayson's sentencing hearing and share concerns with the Ministry of Justice colleagues in the Mental Health Caseworker team.