2022

Noted (AI summary) The response acknowledges concerns about access to child and adolescent mental health services (CAMHS) in West Sussex. It outlines national initiatives to increase funding for and access to mental health services, including potential waiting time standards, and mentions a public call for evidence.

Noted (AI summary) The response acknowledges the concerns raised and references actions taken by Tameside and Glossop Integrated Care NHS Foundation Trust, including a Root Cause Analysis and increased medical rota. It also notes that the CQC received assurance regarding a review of the sepsis pathway and retraining for staff. The Trust is planning to pilot an eNEWS application across its surgical wards to improve the accuracy and speed of data recording and to eliminate errors in early score warning calculation. The Trust's incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting.

Noted (AI summary) The Department acknowledges the concerns, states that NHS England engaged with the Trust, and that the CQC did not identify a need for further investigation of this specific case but continues to monitor the Trust’s performance.

Noted (AI summary) The MHRA states that no action is required, explaining existing systems for unblinding clinical trials and the responsibilities of those executing the processes, particularly regarding informing participants and documenting contact with treating physicians.

Noted (AI summary) Learning from this case will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums to improve outcomes for the population of Greater Manchester. Response contains no content.

Noted (AI summary) HMP Lowdham Grange has updated its DIC checklist to include the Oscar Journal. The use of ACCT tick sheets has been discontinued and all records are contained within the ACCT book. This is a response from a coroner to HMP Lowdham Grange, acknowledging the measures taken and suggesting further alignment with Chief Coroner guidance on disclosure.

Noted (AI summary) The Department for Transport explains that there is no legal requirement to hold a driving licence to register a vehicle, or to become the keeper of an already registered vehicle, and outlines circumstances where this might occur.

Noted (AI summary) Oldham Council has amended the wording on licenses, added blind cord safety as a license condition (checked at every property visit), briefed enforcement officers on blind cord safety, and added related information to the Council's website. A new selective licensing scheme was also reintroduced in July 2022. The Department acknowledges the coroner's concerns but believes awareness campaigns are key. They support RoSPA's 'Make It Safe' campaign and will consider how to strengthen its reach.

Noted (AI summary) Mercedes-Benz clarifies its role as a supplier of a 'cowl' chassis and states that the modifications to the vehicle were the responsibility of Firma Sommer, who converted it into a complete vehicle. The driver was dismissed, and UPS details its driver training and assessment procedures, including a 'Space and Visibility' program. The company refutes that it provides no feedback.

Noted (AI summary) NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare Trust to amend the Pan-Dorset Standard Operating Procedure and discussing with AMHPs how to succinctly share information with GPs. The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022. Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The AMHP service managers will ensure review of records before assessment and there is a new mandatory field to notify the allocated social care practitioner of any Mental Health Act assessment. The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on informal patient status, ensuring comprehensive discharge summaries are sent to GPs after Mental Health Act assessments. The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical conditions make specific training impractical for non-medical personnel. Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff to use Niche for logging decisions, and are including a session on log keeping in Vulnerability 4 training; revised processes are in place to monitor training activity. The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments. The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric admissions. They will also discuss these issues with the President of the Royal College of Psychiatrists. The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services in neuroscience centers in ICSs. The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting out further details.