2023

Noted (AI summary) NHS England will investigate why the Trust informed the deceased that funding was needed for their Gender Dysphoria Clinic, and will ensure the Trust follows relevant guidance. They also describe a working group for sharing learning from PFD reports. The Trust has enhanced procedures including a named point of contact, staff training on trans needs and mental health, and a revised assessment protocol that includes gathering information from family/carers. These changes were implemented from 20th March 2023. The Trust acknowledges the concerns and explains the role of the GIC, its collaboration with other services for mental health care, and the national agreement needed for changing patient prioritisation between clinics. They state they will discuss patient transfers with commissioners.

Noted (AI summary) NHS England expresses condolences and explains its role as a facilitator for system partners working to deliver recommendations from a Public Health England review on prescribed medicines. It describes national resources and notes actions taken by the BLMK ICB and Hilltop Surgery regarding opiate prescribing audits and medication reviews. The response also mentions a working group that shares learnings from PFD reports. Hilltops Surgery reviewed the case, audited patients on high-dose opioids, ensured 3-monthly reviews for certain patient groups, discussed the case with the Integrated Care Board, and arranged a meeting to review NICE guidelines on safe prescribing. The surgery also implemented face-to-face medication reviews and a call-and-recall system.

Noted (AI summary) Cornwall Council is awaiting a response from the Porthleven Food Festival event organiser regarding additional safety measures. The council will also write to all harbours and event organisers for events near harbours, making them aware of the incident and asking them to consider harbour edges as part of their risk assessment process, to be completed by the end of April 2023. The HSE clarifies its regulatory remit regarding Porthleven Harbour, stating it only applies where a work activity is taking place. It states that vires in relation to festivals and other public events falls to the Local Authority, in this case the licensing arm of Cornwall Council and their Environmental Health Office (EHO). The HSE will visit to review the health and safety arrangements at the commercial crabbing area. Porthleven Harbour & Dock Company expresses condolences and states that the Porthleven Food Festival is responsible for all health and safety matters. They state that there is no evidence of where the deceased fell into the water or that he fell at all and that the report does not point to failure of the Harbour & Dock Company to recognise potential public danger. They are committed to ongoing reviews of health and safety issues.

Noted (AI summary) Betsi Cadwaladr University Health Board acknowledges concerns regarding ambulance handover delays and outlines various improvement plans, including implementing frailty assessment on arrival, improving patient flow, and developing a 7-day discharge lounge. Joint reviews of patient safety incidents from handover delays are being rolled out across Wales. The Welsh Ambulance Services NHS Trust references previously provided information regarding actions taken to address patient safety and reduce handover delays, including the Clinical Safety Plan and Reducing Patient Harm Action Plan. It offers to meet and discuss the response in more detail.

Noted (AI summary) NHS England acknowledges the concerns raised regarding the lack of automatic flags for non-responders to cervical screening in GP systems, clarifies the routine invitation process, and highlights ongoing work to improve screening uptake. TPP confirms that SystmOne has an automatic alert for cervical smears, irrespective of whether a patient has had one, but GPs are not informed when patients don't respond to invitations and that alert is not in the system. EMIS expresses condolences and states that their system already meets the recommendation of including an automatic flag/alert when a patient fails to attend for cervical screening as part of the National Screening Programme. They state that the System has an alert reading “Cervical Smear due or outstanding” that displays each time the patient’s record is opened, and also that GP practices can extract lists of patients who remain eligible but are not up to date with their cervical screening. The Department of Health and Social Care acknowledges concerns about patient record systems and alerts for non-responders for smear tests and states NHS England is creating a new IT Cervical Screening Management System (CSMS), due to go live in Quarter 1 2024/25, that will allow GPs to review a list of their non-responders.

Noted (AI summary) The MHRA convened the Isotretinoin Expert Working Group (IEWG) to evaluate data on risks associated with isotretinoin and the Implementation Working Group has had two meetings in March 2023 and is making good progress with a further meeting planned in mid May 2023; the report of this review will be published shortly. The MHRA published a report on isotretinoin's side effects and issued a Drug Safety Update. An Implementation Working Group is developing recommendations for safe introduction of new measures, with outputs to be made public. The Department of Health and Social Care acknowledges concerns regarding Isotretinoin and refers to the MHRA's response; they note that the Isotretinoin Implementation Working Group has met and is drafting a report for the Commission for Human Medicines, with the aim of presenting their advice in July 2023.

Noted (AI summary) The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.