2024

Action Planned (AI summary) Nottinghamshire Police is revising its policy to ensure consistent procedures for supporting suspects of relevant offences, irrespective of whether they are arrested or attend voluntarily. The revised policy will include an automatic referral to Liaison and Diversion (healthcare services) and is planned for implementation by 1st March 2025.

Action Planned (AI summary) A LeDeR review is in progress to look at the care delivered, and NHS England is sharing learnings from PFD reports nationally via a working group. The response provides context and explanation but does not describe completed actions. The CQC has received and accepted an action plan from the Hull University Teaching Hospitals NHS Trust following Mr. Lodge's death, and is monitoring progress through regular engagement and a monthly Quality Improvement Group. They have also requested evidence of action taken following the death, and will check compliance with regulations during the next inspection. The Trust outlines actions taken since January 2022, including the creation of NHS Humber Health Partnership and various groups sharing knowledge to improve patient safety. They have implemented a new NEWS2 escalation process, mandatory training, and a frailty pathway, and are actively participating in the Learning Disabilities Mortality Review programme.

Action Planned (AI summary) National Highways has agreed, but not yet secured, business case and funding for the Average Speed Camera System (ASCS) and work is scheduled to commence in Q1 2025/26. They plan to complete the initial design completion package for ASCS and speed limits by March/April 2025.

Action Planned (AI summary) NHS England acknowledges the long waits for ADHD services and describes a national programme to improve access, including exploring digital options for diagnosis and support, and moving to a needs-based approach. They have also developed guidance for systems to manage medication shortages. The RPS published a report on medicines shortages in Nov 2024 and will consider how to raise awareness of these issues through future communications and engagement and with professional bodies for pharmacy.

Action Planned (AI summary) The government has set delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS, including improving A&E and ambulance wait times. In Spring 2025, the Government will publish its 10-Year Health Plan which will set out radical reforms for the NHS. NHS England is working to improve Category 2 ambulance response times and urgent and emergency care services by growing the workforce, improving hospital flow, reducing handover delays, speeding up discharges, and expanding community services, and has set targets for 2024/25. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions.

Action Planned (AI summary) The Trust is drafting a business case for NHS funding for a new EPR across the whole Integrated Care System (ICS), with deployment expected to take 18-24 months once funding is secured.

Action Planned (AI summary) NHS England will continue to support provider Trusts to deliver appropriate training and support to staff to deliver reasonable adjustments and accessible communication for patients. NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. The DHSC is rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism and NHS England is rolling out further training for staff working in mental health services to upskill staff in supporting autistic people in contact with those services.

Action Planned (AI summary) While hospitals are responsible for HHLS safety, the DfT is considering legislation to ensure safety at all HHLSs and will assist DHSC in developing options for an HHLS database. DHSC states that NHS England now has the contact information for accountable managers at all Trusts operating HHLS and has worked with them to implement requests from Bristow's Helipad operator. DHSC says it is engaging with NHS England and the Department of Transport to determine how best to implement the recommendation to develop a database of HHLSs. The Trust amended the EMRT policy to clarify when EMRT calls are appropriate even with a DNACPR in place, communicated the updated policy to staff, and aligned wording with the Treatment Escalation Plan policy. They also commenced a cascade training programme for swallowing safety, trained nurses, and re-circulated dysphagia guidelines.

Action Planned (AI summary) The Department is reviewing information on the Better Health - Start for Life website regarding the safe use of baby carriers to ensure it is sufficiently prominent. They are also considering ways to supplement the content and engaging with key stakeholders to ensure the messaging is correct regarding the use of baby carriers and breastfeeding. NHS England acknowledges the need for clearer guidance on safe sling use and will work to improve the visibility and linking of existing resources on NHS.UK. They have referred the issue to NICE for consideration and passed details to UNICEF-UK. Several charities have agreed to advise parents that hands-free breastfeeding using slings and carriers is unsafe and should not be attempted. The Lullaby Trust is funding research and will convene a roundtable to agree simpler, consistent messaging for parents and stakeholders on safe sling and carrier use. OPSS is aware that Merton Council Trading Standards are investigating the specific product involved in the death, focusing on its compliance with safety standards. OPSS will also bring any updates to Government or NHS advice regarding infant safety in slings to the attention of trade associations and review the designation of the voluntary standard.