2024

Noted (AI summary) The Metropolitan Police Service will deliver learning to staff and officers highlighting the importance of strict location sharing and compliance with standard operating procedures. Surrey Police reviewed records of calls and concluded that calls were handled correctly and promptly passed to the MPS. They agree with MPS that there was no failure in communication between Surrey Police and MPS.

Noted (AI summary) Sunlight Care Group has updated policies, conducted a Serious Incident Review, and commenced a training program for staff. The training covers topics such as recognizing self-neglect, home safety, nutrition, and risk management, with a detailed schedule outlined in the response. The council has already completed a Safeguarding Adults Review referral and held a meeting with Sunlight Care, implementing a quality improvement plan and enhanced monitoring. They also plan further actions including a learning event with ASC, Sunlight Care and ELFT, a review of safeguarding procedures and training on implementing inquest lessons. The DHSC acknowledges the concerns raised in the report, referencing the Care Act 2014 and Mental Capacity Act. They highlight existing resources like the Care Workforce Pathway without committing to specific new actions. The Trust has increased time slots in the dressing clinic, staffed it with a substantive nurse, and will review with staff the need to proactively arrange professional meetings when they witness concerns. They also describe changes to wound care pathways.

Noted (AI summary) NHS England acknowledges concerns about oesophageal intubation and the PUMA guidelines and states they will clarify the future direction of the Never Events Framework. They also note that all PFD reports are discussed by a working group to share learnings. The organisations agree with the coroner's concerns and highlight their existing work, including the 'no trace = wrong place' campaign, endorsement of PUMA guidelines, and emphasis on capnography in anaesthesia standards. They also express support for unrecognised oesophageal intubation to be a nationally reportable incident. The RCEM expresses support for adequate staffing, multidisciplinary simulation training, equipment standardization, intubation checklists, and capnography use, referencing an existing framework for collaboration between Emergency Medicine and Intensive Care Medicine.

Noted (AI summary) The Department of Health and Social Care acknowledges concerns about waiting times for heart treatment and highlights commitment to reducing waiting lists, but notes the Trust believed the patient's complication would have happened regardless of waiting times.

Noted (AI summary) The Secretary of State acknowledges the coroner's concerns regarding the Online Safety Act and its application to potentially harmful content on platforms like Amazon, but states that enforcement is the responsibility of the police and CPS. The response also clarifies the remit of the Ministry of Justice regarding the Suicide Act 1961.

Noted (AI summary) The HSE states that current guidance on safe stacking, loading, and unloading of bales is sufficient and does not require further images or supporting material, but they will keep the report on record for consideration when it is next reviewed.

Noted (AI summary) NICE acknowledges the concerns regarding clozapine and blood cancers but states that the MHRA is the responsible body for medicine regulation and safety. NICE welcomes any findings that may impact its current recommendations and advice. Viatris states its clozapine product is safe when used as prescribed and that ongoing monitoring shows no change in the benefit risk profile, so no action is proposed. Response contains no text. Response text consists only of A6 and A7.

Noted (AI summary) The Royal Pharmaceutical Society explains that the BNF provides a general overview and may not include all information necessary for prescribing, recommending referral to a specialist for bipolar disorder. They will continue to monitor for additional information around the management of bipolar disorder for future updates. BMJ acknowledges the coroner's concerns regarding BMJ Best Practice's content on bipolar disorder treatment. They state that the tool is a reference for medical professionals and that content is regularly reviewed and updated, but the decision on treatment remains with the prescribing clinician. They highlight the importance of consulting multiple sources and checking product information sheets for medications. NICE acknowledges the coroner's concerns regarding their bipolar disorder guideline (CG185) and its consideration of the two polarities of bipolar disorder in long-term treatment. They will discuss this area with their topic experts and review any new evidence, updating recommendations if necessary.