2023

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance response times. The response references the 'Delivery plan for recovering urgent and emergency care services' and notes improvements in ambulance response times and handover delays but acknowledges more work is needed.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns regarding the use of Nearest Relative powers under the Mental Health Act. The response notes the Responsible Clinician's powers to bar requests for discharge and states the government does not intend to amend the Nearest Relative powers.

Noted (AI summary) NHS England acknowledges the concerns, states that it is not the appropriate organisation to respond to many of them, but will consider the Trust's response and has been sighted on the Trust’s Patient Safety Serious Incident Review Report. It also draws attention to NHS England’s national Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The MPS has the Affinity Protocol in place since 2021 and will undertake work as part of the implementation of the Right Care, Right Person to ensure policies of all parties align and there is a clear understanding of definitions and terminology used. The Home Office describes the Right Care Right Person (RCRP) approach to assist police decision making. It states that the investigation of a missing person report is an operational decision for individual police forces and refers to the MPS Affinity Protocol. The Trust has updated its Missing and AWOL policy, reviewed procedures for patients leaving acute wards, and changed observation guidance. They will review their Risk Assessment policy and the Grab Pack's alignment with local policies, including seeking external expert opinion, with a 3-6 month timescale.

Noted (AI summary) Dorset and Wiltshire Fire and Rescue Service states its commitment to the Joint Emergency Services Interoperability Principles (JESIP) and highlights that the challenges of intra-operability with partners is an area of focus for the Blue Light Group on 18 September 2023. Dorset Police has updated the Niche system by adding a drop-down list regarding Google Translate translation software. They are also implementing changes to Section 2 of Occurrence Logs on Niche, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question. HM Coastguard updated its Capability Matrix to provide partner emergency services across the UK with information on its communications capabilities and uploaded it to the MCA's ResilienceDirect page. 'Connect' call capabilities also now feature in routine exercising with other stakeholders and during the Emergency Control Room visits. The National Fire Chiefs Council (NFCC) supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP) doctrine and will commence work in autumn 2023 to establish a process of providing additional national assurance about the application of JESIP across blue light services. The Trust outlines its existing communication protocols with other emergency services, including ambulance dispatchers' ability to communicate with air ambulances and telephone links with SAR aircraft via the Maritime and Coastguard Agency. It says its staff endeavour to use clear language in all communications, adhering to JESIP principles. NHS England acknowledges concerns but notes many fall outside its remit. It encourages local systems to consider accessibility of resources and highlights agreed actions between Dorset Healthcare Criminal Justice Liaison and Diversion Team and Dorset Police to improve working practices. NicheRMS circulated the facts of the coroner's report to Niche Technology customers and is seeking views on changes needed to reduce the chance of a similar occurrence. A temporary solution is proposed, pending consultation with all Niche forces, that will involve staff making the appropriate detention log entry as occurs for other risk assessment questions. The College of Policing will amend the Detention and Custody APP checklist to include a question about previous arrests. Once this amendment has been made the College will write to forces informing them of the change. The RNLI is updating its page on the government's "ResilienceDirect" platform with details about its capabilities and pulling together material to be shared directly with emergency services partners. The RNLI will also work with the Coastguard to participate in partner awareness 'open day' events. NPAS and HMCG have agreed to a series of joint familiarisation briefings for all staff and will develop a joint "quick action card" prioritising the need for the Host Force to set an Emergency Services channel on Airwave. Monthly Comms meetings and quarterly meetings will be held and reciprocal visits between the HMCG / NPAS Ops Centres will be arranged. AACE will work with partners in police, fire and rescue, and search and rescue and the matter of concern will be discussed at the UKSAR Communications working group. The Medical Advisor to NARU is aware of the concerns and is looking to ensure learning from this tragic incident takes place.

Noted (AI summary) The Trust clarifies the extent of family involvement in the patient's discharge and references its Service User and Carer involvement Strategy but does not describe specific actions taken or planned in direct response to the concerns.

Noted (AI summary) The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work.