2022

Noted (AI summary) GMP has revisited its Graded Response Policy (GRP), implementing a new GRP on 1 February 2022 using the THRIVE framework for risk assessment. They are also implementing a new IT system called 'Sherlock' by August 2022 to improve information storage and access in the FCC. The IOPC acknowledges the report and highlights its power to make organisational learning recommendations to relevant bodies. They state that GMP has a legal obligation to respond to the recommendations in writing by 20 July 2022.

Noted (AI summary) The Home Office acknowledges the concerns raised, explains the existing legislative framework, and states that it prefers to encourage sensible planning rather than mandating every element of it through legislation, pointing to guidance from the Cabinet Office.

Noted (AI summary) The consultant psychiatrist will now email his secretary of planned follow-ups for patients and advise her to remind the patient two weeks before the scheduled time to make an appointment. If they do not respond, the GP will be informed that they are no longer attending the clinic. No actions or stance were discernible from the provided text.

Noted (AI summary) CHEM notes the concerns raised regarding public entry into containers and will welcome suggestions for additional warnings for operators. Biffa is reviewing operating instructions to ensure clarity on the use of viewing windows, reminding customers about using locks effectively, and continuing to develop relationships with charities supporting rough sleepers. Dennis Eagle explains the design intent of the side window on their refuse vehicles, stating it's for viewing the discharge of container contents and not for viewing the floor of the tailgate. BSI consulted experts and will raise the issue of bin locks when the committee next meets to discuss if changes to existing standards are appropriate.

Noted (AI summary) The Department of Health and Social Care outlines existing NHS services and policies related to electronic health record transfer and access.

Noted (AI summary) The Nursing and Midwifery Council outlines existing standards and processes related to DNACPR understanding and fitness to practise, without describing new actions taken or planned. Avalon Nursing Home updated DNACPR and RESPECT forms in care plans, discussed clinical judgements with a local surgery and paramedics, provided refresher training in basic life support and first aid, and amended its policy on calling an ambulance and DNACPR.

Noted (AI summary) The ECB intends to circulate communications to appropriate representatives, including a list of steps from the CAA, within one month and emphasize the need to share the information directly with players. All corporate travel for ECB employees and representatives must be booked through the ECB's travel management company Ventur. The RFU cascaded the findings in the Regulation 28 Report to all clubs involved in the Premiership. The RFU also raised this subject at the June meeting of the Professional Game Board. The EFL reissued guidance to all Clubs, which was received in March 2021. The EFL will reissue a link to the guidance in advance of each transfer window. The British Horseracing Authority briefed its Board and prepared a draft guidance note to send to its member bodies and engaged with the Civil Aviation Authority (CAA). The Department for Transport and the CAA are reviewing the powers available to them in investigating breaches of aviation regulations and what powers they would find of assistance in their investigative and enforcement role. The FA states they were not aware of the coroner's report until it was provided by the English Football League. The FA relayed CAA guidance on illegal flights to clubs and Registered Intermediaries in March 2021. The Jockey Club requires aircraft operating at its racecourses to obtain prior permission, demonstrate pilot licensing, provide aircraft registration and insurance, and confirm whether flights are private or commercial. The Jockey Club and Helicopter & Aviation Services Ltd provide records of aircraft activities to authorities when requested. The organisation circulated a note to its members recommending that they do not pay for or use unlicensed commercial flights, sharing the concerns of the Dorset Coroner. The Professional Footballers Association has written to its current members and put information on its website to raise awareness on the issue of unlicensed aircraft, and attached the guidance issued by the CAA. UK Athletics has distributed information regarding private flights to World Class Programme athletes, coaches, support staff, and known agents, emphasizing the need to check the legality of flights. The Institute of Directors included a statement in its 'Influence' email to 20,000 members and posted a notice on its website warning of the dangers of unauthorised flights, following a request from the Civil Aviation Authority. The LTA sent a communication to relevant players on 9 August 2022 regarding commercial flights from unlicensed operators, including a link to CAA guidance. The Confederation of British Industry plans to publish an article on employee wellbeing and safety linking to the Sala case, use social media to amplify the importance of employee well-being and safety, and flag the case to its account managers who manage the CBI's aerospace members. The Premier League will send correspondence to the Legal, Club Secretarial, and Football departments at each of the Clubs. The Premier League met with Clubs at the Annual General Meeting on 9 June 2022 and raised the issue to the Chairs/Chief Executives/Owners attending. The Rugby Football League wrote to all member clubs advising them of the situation regarding private flights and asking them to ensure they do not use such flights. The Department for Digital, Culture, Media and Sport shared CAA guidance with sports organisations, Live music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians' Union. Motorsport UK will publish advice to its license holders on its website and in its monthly ezine regarding air-worthiness of chartered aircraft and pilot qualifications. The RFU requested Premiership clubs review the PFD report on commercial flight chartering and ensure flights are legal and have required authorisations, certifications and permissions, and pass the information to relevant employees. The British Chambers of Commerce circulated briefing materials to its Chamber of Commerce members, raised the issue in a call with Chamber of Commerce CEOs, and highlighted the importance of taking action at the BCC Board. UK Sport asserts that the use of illegal private plane journeys is not permitted with their funding and that the risk of government funded sports using them is minimal. The EFL circulated a CAA notice to club secretaries raising awareness of the risks of illegal public transport using unlicensed aircraft. The Executive Association of Great Britain stated that the report and concerns are not applicable to their particular circumstances as they do not arrange travel for members, and members do not travel by air to attend meetings.

Noted (AI summary) Humankind has implemented a standard operating procedure for prescription deliveries, including mandatory witnessed delivery and recording in the service user's notes. They have also established a contact procedure and contingency plan for failed deliveries, and record failed deliveries as incidents in their management system. Boots UK acknowledges the concerns raised and states the gravitas is duly noted.

Noted (AI summary) NICE acknowledges the correspondence but states that responsibility for the content of the BNF lies with the publishers, BMJ Group and Pharmaceutical Press, and therefore NICE cannot comment on the concerns raised. The Royal Pharmaceutical Society will add additional information regarding acute pulmonary reactions to the nitrofurantoin monograph in the BNF, specifically highlighting it in an additional section of the side-effects information, and will also add information on the importance of counselling patients on the possible symptoms of acute pulmonary reactions and the necessity of promptly reporting such symptoms. The medical group has emailed prescribing clinicians about nitrofurantoin side effects, will discuss the matter at a Significant Event Analysis Meeting, plans to provide written information to patients, and will contact the Local Medicine Management Team to suggest changes to local guidelines. The MHRA will request that Marketing Authorisation Holders strengthen the wording in the UK Summary of Product Information (SmPC) and Patient Information Leaflet (PIL) regarding pulmonary reactions to nitrofurantoin. The MHRA will also communicate any SmPC and PIL updates, to the BNF, and will communicate to UK healthcare professionals to inform them of these updates via the Drug Safety Update.

Noted (AI summary) The Trust outlines actions taken in response to concerns, including updating guidelines for maternal blood pressure checks and CTG interpretation, changing processes for escalating concerns, and ensuring timely review of blood test results. They also describe actions related to training and competence assessment of midwives. The Trust requests redaction of specific concerns and responses from publication, arguing they could identify individual clinical staff and contain personal information.

Noted (AI summary) The Mayor acknowledges the concerns regarding police pursuits but states that operational policing is under the Chief Constable's control. The Mayor highlights existing governance structures and oversight of ethical considerations around police pursuits. West Yorkshire Police details actions taken in response to concerns about police pursuits, including re-evaluating local arrangements, liaising with national leads, updating training, and revising risk assessment processes. They also describe post-incident procedures and national efforts to standardize driver training.

Noted (AI summary) The Secretary of State acknowledges concerns about including 'obesity' as an indicator of abuse and neglect in safeguarding guidance, highlighting existing guidance on safeguarding children's welfare and health. They note existing initiatives to improve access to services for children living with overweight or obesity and refer to the Independent Review of Children’s Social Care, stating that the concerns will be considered in the context of the review's recommendations.