2023

Noted (AI summary) Acis Group acknowledges the coroner's concerns, referred the issue to the Regulator of Social Housing and the National Housing Federation, and raised awareness within the social housing sector, asserting no breach of regulatory standards or statutory obligations.

Noted (AI summary) Church Lane Surgery updated their patient history templates, provided training to staff on collecting and recording family history of IHD, and restructured the on-call system for the Duty doctor by adding un-booked telephone and face-to-face slots. London North West University Healthcare NHS Trust argues that the patient's management in the emergency department was appropriate based on national scoring and existing chest pain pathways and describes the introduction of an Emergency Assessment Unit designed to improve waiting times.

Noted (AI summary) The CQC states that the location where the death occurred was not registered with them and appears to fall outside the scope of registration and regulation by them. They have requested interested person status and an extension to gather further information. The CQC states that the sheltered accommodation where the deceased resided is not registered with them and therefore not regulated by them, so they cannot comment on the specific concern raised.

Noted (AI summary) SWASFT has reminded all Private Ambulance Providers (PAPs) of the Appropriate Care Pathway Policy regarding GP referrals and the Dorset Integrated Urgent Care Service (IUCS) GP Alert service. The ECS has been successfully reintroduced and they are reviewing and updating their Business Continuity Plans, looking at adopting the Scribe ECS as a secondary fall-back system. Dorset Integrated Care Board acknowledges the concerns but states Dorset has a well-established Access Mental Health service. They state SWASFT are in discussions with Dorset HealthCare and the police about operational processes and developing the trusted assessor model. The Department acknowledges the concerns raised and outlines the regulatory framework for health and care professionals. It details the SCoPEd framework being adopted by professional counselling bodies but notes these bodies do not fall under Government oversight.

Noted (AI summary) The Council provides a summary of Adult Social Care involvement prior to Mr. Hall's admission and highlights existing procedures and challenges in the social care market, including working with the independent sector and addressing gaps. It acknowledges challenges in the social care market and are continually working to address these through more flexible, sustainable and outcome focussed services.

Noted (AI summary) The IOPC expresses condolences and explains its role in the police complaints system. It details the recommendations made to Durham Constabulary, their response, and the IOPC's follow-up actions to seek further clarity on the acceptance of recommendations. DWP expresses condolences and states that existing guidance and support are adequate for vulnerable customers. They describe the call-back procedure followed and note that the ESA agent did not stop Ms Holmes’ benefit pending receipt of a PW1 form, indicating recognition of her vulnerabilities. TEWV acknowledges concerns and details actions taken including confirming assessment methods, developing an interim policy to address disputes between police and mental health services, and preparing a patient safety briefing on actions to take when disputes arise with partner agencies. The Police and Crime Commissioner acknowledges receipt of the report and expresses condolences. They state they have discussed the concerns with the Chief Constable, who has implemented an interim escalation policy with TEWV pending the roll-out of the national ‘Right Care Right Person’ approach. The constabulary has worked with TEWV to develop a strong partnership plan, implemented an interim escalation policy, and will train frontline officers with a national training package and local guidance.

Noted (AI summary) Outwood Grange Academies Trust details the mental health and wellbeing services involved with the academy, referral processes, and discharge procedures. They note that further guidance from the DfE on support in schools for pupils who are transgendering is still awaited. The DfE is working with the Minister for Women and Equalities to develop guidance to support schools and colleges in relation to children who are questioning their gender, with a public consultation planned before publication. The Department of Health and Social Care outlines NHS England's plans to increase access to community mental health services for children and young people, and to implement new access and waiting time standards. They also describe NHS England's overhaul of children’s gender identity services following recommendations from Dr. Cass.

Noted (AI summary) ABTA acknowledges the coroner's concerns and outlines its role in providing guidance to travel industry members and consumers, particularly regarding health and safety. They highlight their work with the FCDO and their consumer safety information, but state they are not aware of the full facts in the specific case. The FCDO has enhanced its Travel Advice on swimming safety to include a link to the Royal Life Saving Society’s (RLSS) “Water Safety on Holiday” page in the “Swimming safety” section of the “Safety and Security” page.