2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 63% average).

Clear 413 results
Celia Sanderson
All Responded
2023-0052Deceased 10 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.
Noted (AI summary) NHS England acknowledges the concerns, discusses Greater Manchester Integrated Care's challenges, and points to national guidance on UEC recovery. The Regulation 28 Working Group will share learnings nationally. The Department of Health and Social Care acknowledges the concerns raised, noting that NHS England has addressed them, including action taken locally and a Major Trauma Network. They highlight national initiatives for urgent and emergency care improvements.
Sandra Lomax
All Responded
2023-0051Deceased 10 Feb 2023 Manchester South
Greater Manchester Integrated Care NHS England
Concerns summary (AI summary) Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
Action Planned (AI summary) Greater Manchester Integrated Care will present learning from the case with the Greater Manchester System Quality Group. Shared learning from this and similar cases will be cascaded to professionals through governance and learning forums. NHS England will share the coroner's report with System Quality Groups and review proposals from The Christie regarding chemo-radiotherapy and stenting services. The Regulation 28 Working Group will discuss all reports received to identify key learnings and emerging trends.
George Kearsey
All Responded
2023-0050Deceased 9 Feb 2023 East London
Barking, Havering & Redbridge NHS Trust Department of Health and Social Care
Concerns summary (AI summary) Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.
Action Taken (AI summary) The Trust has conducted cross-site audits, shared fluid management guidance via the CMO newsletter, and produced training material on Careflow vitals, including a quick video for doctors. A clinical safety assessment is underway, with staff trained and a clinical safety officer being recruited. The Trust completed audits in Geriatrics and Frailty wards showing improvements in fluid chart completion, conducted random spot checks to ensure ongoing compliance, completed a Clinical Safety Assessment on Vital pack, and met with the family to resolve their concerns and invite them to share feedback with nursing staff.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased 8 Feb 2023 Plymouth, Torbay and South Devon
Approved Clubs self-governing schools Chief Constables +5 more
Concerns summary (AI summary) Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Disputed (AI summary) Merseyside Police firearms enquiry officers have completed the South Yorkshire Police training package and are enrolled on Mowbray Partners online training. They will also review cases within one month where firearms were seized or surrendered but subsequently returned, and applications refused/licenses revoked but later granted, aiming to complete this by 2nd October 2023. Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Gloucestershire Constabulary will conduct a review of firearms licensing decisions, as per the letter from the NPCC lead, with a target completion date of 2 October 2023. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. Norfolk Constabulary will commission external training for Firearms Licensing Unit staff starting in May 2023. They will also conduct a review of certificates seized, refused, revoked, or surrendered and then subsequently approved, prioritizing cases not already subject to renewal, with a dip-sample approach to other cases. Essex Police is reviewing decisions to return firearms licenses over a five-year period, prioritizing cases where firearms were seized or surrendered and then returned. They have implemented local training for firearms licensing staff, including a lesson plan developed collaboratively with Kent Police, and external auditors will review the team's compliance. Sussex Police's Firearms and Explosives Licencing Unit believes its process for the return of a certificate is suitably stringent and is catered for within a force policy; the team is working with the national NPCC lead and the College of Policing in developing a national curriculum and learning outcomes for Firearms Enquiry Officers, and will be active participants at the two day CPD event hosted by the College of Policing in May 2023. West Mercia Police will review firearms licensing decisions related to returns, refusals, revocations, and surrenders over the past five years, aiming to complete the review by the end of October. A designated team, including a firearms instructor and tactical advisor, will conduct the review. Kent Police will review 134 firearms licensing cases where certificates were returned after seizure/surrender, or granted after refusal/revocation, assessing them against the current Home Office Statutory Guidance. Local firearms licensing training, including refresher courses and mentoring, is provided, with plans to develop a lesson plan with Essex Police by the end of August 2023. Bedfordshire Cambridgeshire and Hertfordshire Police have instructed a review of firearms seized and returned, certificate holders refused or revoked then successfully reapplied, and holders subject to police intelligence reports over the last five years. New role-specific training is being undertaken by all Firearms Explosives Licencing Unit staff, and an external training package has been purchased. Devon and Cornwall Police invested £3 million into the force's Firearms and Explosives Licensing Unit (FELU). In 2023, training is planned, including integrating firearms licensing into practical scenarios for Personal Safety Training and presenting key learning from the incident at CPD events. The Lord Chief Justice acknowledges the concerns but states that the report does not substantiate the suggestion that judges are not giving appeals the necessary careful and detailed consideration, are applying the incorrect legal test, or are failing to have regard to the statutory guidance. Nottinghamshire Police has identified a dedicated resource to review firearms licensing cases where firearms were seized/surrendered and later returned, or where licenses were refused/revoked and later granted. A sample of cases from a 2021 review will be independently re-reviewed, and all reviews will be completed by 2 October 2023. Durham Constabulary details their history of firearms licensing reform following a 2013 report and states that they are satisfied that their review of decisions to return firearms to licence holders after seizure or surrender was appropriate and subjected to the appropriate level of scrutiny and oversight. Staffordshire Police and West Midlands Police (collaborated service) provided tables that outline certificates seized and returned, revoked, and refused. They have a series of scheduled quality assurance programmes in relation to internal and external audits over decision making. Northamptonshire Police will prioritise reviewing cases where firearms have been seized/surrendered and then returned, and cases where applications were refused/licenses revoked but later granted, completing this by 2nd October 2023. They have secured temporary resources and engaged external companies to audit the unit. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. The Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. Derbyshire Police has implemented IT system improvements for recording and sharing information, ensuring automatic notifications to the firearms licensing team for incidents involving license holders. They are developing a digital learning package for frontline officers and are exploring an independent scrutiny panel. Dyfed Powys Police will undertake a further review of decision files where firearms have been seized following any incident and subsequently returned to the holder. They welcome and support the recommendation of the Coroner to formalise a training programme to encompass all Firearms roles and responsibilities. Warwickshire Police states that they have already responded to the Home Secretary's request in 2021 regarding license applications that were refused or revoked but subsequently granted. The force will direct a review of firearms and shotgun licensing, prioritizing cases where firearms were seized or surrendered but then returned. Suffolk Constabulary will review cases relating to certificates issued between April 2019 and August 2020. For other periods, they will dip-sample cases, with a wider review if concerns are identified, and highlight prior review work undertaken in Autumn 2021.
Stephen Wood
All Responded
2023-0047Deceased 8 Feb 2023 Dorset
BCP Council Department for Transport Dorset council +2 more
Concerns summary (AI summary) A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.
Noted (AI summary) National Highways will conduct a study to identify options for improving road user notification of incidents, aiming to complete it by late Summer/Autumn 2023 and prepare an implementation plan. Dorset Road Safe partnership will add a clear link to their website indicating who to contact regarding road obstructions, highlight associated dangers, and launch a communications campaign across various media platforms to alert road users to obstructions on Dorset roads. Dorset Council, as part of Dorset Road Safe, will introduce a simple reporting process and contact information for obstructions/debris on the road to their website. A communications campaign will be constructed to alert all road users around obstructions/debris on Dorset’s roads using various media platforms. The Department for Transport outlines existing legislation and guidance regarding road obstructions, including the Highways Act 1980 and the Highway Code. They conclude that no further action is appropriate for the Department to take at this stage. BCP Council states that the response letter from the Dorset Police Chief Constable conveys the views of BCP Council, via the Dorset Road Safe Partnership.
Richard Kew
All Responded
2023-0049Deceased 7 Feb 2023 Leicester City and South Leicestershire
Department of Health and Social Care
Concerns summary (AI summary) Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.
Action Taken (AI summary) The MHRA updated its guidance on the safe handling of haemodialysis catheters to prevent air embolisms, including recommendations on staff training and risk assessments, and the Association of Anaesthetists committed to integrating content on catheter-related air embolism into its updated 'Safe vascular access guidelines'.
Ania Sohail
All Responded
2023-0046Deceased 7 Feb 2023 Manchester North
Department of Health and Social Care Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary) Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.
Action Planned (AI summary) Greater Manchester Mental Health NHS Trust has replaced the Recovery and Discharge Plan with the ATAC care plan, developed a care bundle to improve observations, updated its policy regarding patient observations, and provided training on observation standards. NHS England is running Proof of Concepts to expand Summary Care Record access to private hospitals and healthcare services, with learnings to be reported to an Expert Advisory Committee for potential full rollout approval.
Patricia Green
All Responded
2023-0044Deceased 4 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about ambulance demand and delays in Greater Manchester, highlighting national efforts to improve ambulance response times, increase hospital bed capacity, and ensure timely hospital discharge.
Kirsty McKie
All Responded
2023-0043Deceased 4 Feb 2023 Manchester South
Foreign Secretary
Concerns summary (AI summary) There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Action Planned (AI summary) The British Consulate in Bali will place an information banner about methanol poisoning risks in the international arrival area of the local airport from June to December, and the FCDO will engage with the UK Travel Industry and Student Brand Ambassadors to raise awareness.
Benjamin Stanley
All Responded
2023-0042Deceased 4 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary (AI summary) Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and ward admissions.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about A&E waiting times and bed capacity at Stepping Hill Hospital, highlighting national efforts to improve emergency care through increased bed capacity, virtual wards, and funding for timely hospital discharge.
Mary White
All Responded
2023-0045Deceased 2 Feb 2023 Gwent
N/A
Concerns summary (AI summary) Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.
Action Taken (AI summary) Aneurin Bevan University Health Board is reintroducing training on falls risk assessment and prevention, reviewing the falls risk assessment process, and developing an action plan to capture and monitor actions, and is exploring learning from the use of sensors in care homes.
Daniel Futers
All Responded
2023-0040Deceased 2 Feb 2023 Sunderland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary (AI summary) Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.
Noted (AI summary) The Trust states its investigation didn't identify issues with care provided to Daniel Futers or compliance with Trust policies/procedures, except for missing belongings. The response asserts policy regarding patient leave was followed and is fit for purpose and notes ongoing efforts to improve communication with carers/family.
Jason Williams
All Responded
2023-0039Deceased 2 Feb 2023 Dorset
HM Prison and Probation Service, NHS En…
Concerns summary (AI summary) Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Noted (AI summary) NHS England developed a training programme for Adult Safeguarding in Secure and Detained Settings in conjunction with HMPPS and HEE. The response also mentions a Ministry of Justice NPS toolkit. HMPPS will review and develop the key work model to improve safety and reduce reoffending, including making it more flexible. HMP Guys Marsh introduced an assurance check for weekly case notes and a weekly multi-disciplinary meeting to discuss and share information regarding drug ingress, issuing Governor's Notices and harm minimisation guidance as needed. The response refers to the Director General's letter which outlines the actions being taken at HMP Guys Marsh, such as introducing a Buddy scheme, writing local guidance, introducing an assurance check, and a weekly multi-disciplinary meeting.
Andrew Bowles
All Responded
2023-0423 31 Jan 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Sandwell and West Birmingham NHS Trust
Concerns summary (AI summary) A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Action Planned (AI summary) The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be monitored through clinical governance at BSMHFT.
Evelyn Burcham
All Responded
2023-0421 31 Jan 2023 Somerset
Care Quality Commission Department of Health and Social Care Health and Safety Executive
Concerns summary (AI summary) Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.
Noted (AI summary) Aria Care will direct all future requests for riser/recliner chairs to Shackleton's, ensuring lockable handsets, and inform newly admitted residents of this requirement from December 1st, 2023. They are also working to replace existing chairs without lockable handsets and will reduce the use of riser/recliner chairs across the organization. HSE outlines the regulatory regimes applicable to the circumstances. HSE has contacted CQC on the patient safety aspects and notified OPSS regarding consumer product safety. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs.
Donald Brown
All Responded
2023-0037Deceased 31 Jan 2023 Gloucestershire
Gloucestershire Hospital NHS Foundation…
Concerns summary (AI summary) Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.
Action Taken (AI summary) The hospital secured an additional trainee radiologist and aims to create a fellowship post. It is recruiting inpatient navigators for call triage, training radiographers to vet scans, and investigating an AI tool for scan triage.
Nathan Forrester
All Responded
2023-0035Deceased 31 Jan 2023 Inner South London
HM Prison and Probation Service, NHS En…
Concerns summary (AI summary) Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
Noted (AI summary) NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. All reports received are discussed by the Regulation 28 Working Group. All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff.
Samantha Boazman
All Responded
2023-0034Deceased 31 Jan 2023 Leicester City and South Leicestershire
Inmind Healthcare Group
Concerns summary (AI summary) The report raises concerns that emergency response protocols at the hospital involved staff assessing a situation and then collecting equipment, rather than bringing it immediately, and observations were recorded in a predictable manner, not therapeutically.
Action Taken (AI summary) Following the death, an emergency bag is now in every ward in all Inmind hospitals. Regular training and competency assessments are now undertaken regarding observations, and a new radio protocol has been implemented for staff to communicate effectively in emergencies.
David Nash
All Responded
2023-0033Deceased 31 Jan 2023 West Yorkshire (Eastern)
NHS England
Concerns summary (AI summary) The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.
Action Planned (AI summary) NHS England will remind regional complaints teams to share final responses with providers, include a reference to the Report in the next National Learning Report, and remind teams to liaise with coroners when inquests run parallel to complaints.
Andrew Shirley
All Responded
2023-0063Deceased 27 Jan 2023 Worcestershire
Various
Concerns summary (AI summary) HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.
Action Planned (AI summary) Following Mr Shirley’s death, a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust was undertaken. The Access Team call handler aide memoire has been updated. Practice Plus Group have healthcare staff being trained to deliver ACCT training. Training compliance at HMP Hewell is currently 88%, and further dates have been arranged to ensure full compliance by 31 March 2023. Training has also been delivered to all healthcare staff regarding the initial segregation health screen. HMP Hewell is delivering training sessions that incorporate both ACCT v6 and SASH training to all staff with the expectation that this will be completed by July 2023. HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and delivered a training session to all Duty Governors in March 2023.
Jayden Booroff
All Responded
2023-0036Deceased 27 Jan 2023 Essex
Essex Partnership NHS Foundation Trust Essex Police
Concerns summary (AI summary) Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency services regarding escaped detained patients.
Action Taken (AI summary) The Trust handover process was reviewed and the electronic handover sheet was revised. The Trust engagement and supportive observation processes were reviewed and the observation recording document was revised. Staff have been provided training on managing patients with challenging behaviour. The Trust have an Essex wide single point of access with a priority ‘emergency services line’. Essex Police has aligned its Missing Persons Procedure with College of Policing guidance. Essex Police has created the Essex Police Mental Health and Missing Person’s Constable post. Frontline uniformed officers have received specific training on the Mental Capacity Act and police powers.
Andrew Largin
All Responded
2023-0027Deceased 25 Jan 2023 Inner North London
East London Foundation Trust
Concerns summary (AI summary) The report identifies a failure to allocate a team member promptly after discharge from the crisis team, a lack of reassessment despite concerning information, and poor communication between teams regarding patient pathways.
Action Taken (AI summary) The Trust has reviewed procedures, met with managers, and is implementing a training programme for Neighbourhood Teams to highlight clinical risk when triaging incoming referrals, which started in March 2023 and runs monthly for 6 months. WWNT members will be required to attend the next Coroner’s Training provided by the Trust’s Legal Affairs Team.
Dorothy Jones
All Responded
2023-0020Deceased 20 Jan 2023 Gwent
Department of Health and Social Care Welsh Ambulance Service NHS Trust
Concerns summary (AI summary) Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc interventions not supported by policy.
Action Planned (AI summary) The Trust has focused on actions to mitigate real time avoidable harm and has sustained reporting to their Trust Board on progress. Clinicians from the Clinical Support Desk review waiting calls and will speak directly to 999 callers and/or the patient to establish if other methods of response might be suitable, and to ensure the priority assigned to the call does not need to be adjusted. The Minister notes the concerns and states that the Welsh government is working with WAST and health boards to improve ambulance handover times and response times and drive delivery of improvement plans.
Nicholas Dumphreys
All Responded
2023-0021Deceased 19 Jan 2023 Cumbria
National Police Chiefs Council
Concerns summary (AI summary) Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy to prevent faulty decommissioned police vehicles from being sold, and a lack of national garage standards risks inadequate maintenance.
Action Planned (AI summary) The NPCC has reorganised its fleet structure and is establishing a new NPCC-led governance and delivery structure to oversee police fleet issues. They will also reissue disposal advice under NPCC branding and are working to develop national vehicle servicing standards and a code of practice.
Joseph Price
All Responded
2023-0019Deceased 19 Jan 2023 County Durham and Darlington
NHS England
Concerns summary (AI summary) Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.
Action Planned (AI summary) NHS England acknowledges the concerns and is refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history. All reports received are discussed by the Regulation 28 Working Group to ensure that key learnings are shared across the NHS.