2024

Noted (AI summary) HMPPS acknowledges concerns about ACCT observations, shower rails, personality disorder training, and cellular confinement, explaining existing policies and planned improvements without committing to specific new actions.

Noted (AI summary) NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe internal processes for reviewing PFD reports. The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A Joint Working Protocol is being put in place and the SLA between MSE and EPUT is being addressed at a senior level. The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also provided guidance on assessing patient capacity and detaining patients under Section 5(2) of the Mental Health Act, including notification procedures and patient rights.

Noted (AI summary) NHS England acknowledges the concerns raised but states that they fall under the remit of East Suffolk & North Essex NHS Foundation Trust; they note that the Trust has taken learnings and is taking actions to ensure staff have Immediate Life Support training and that Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group. East Suffolk & North Essex NHS Foundation Trust has implemented actions including mandatory immediate life support training for certain staff, and monthly quality audits of resuscitation trolleys.

Noted (AI summary) The Welsh Ambulance Service explains why it carries naloxone but not flumazenil, stating that flumazenil is not safe for widespread use and that ambulance personnel are trained in more appropriate techniques for benzodiazepine overdose.

Noted (AI summary) ALLMI provides background on their organization, existing safety measures, and training programs for lorry loader operators. They dispute the coroner's findings, arguing that existing standards and training should have been considered and request industry representation in future investigations.

Noted (AI summary) NHS England highlights the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, designed to localize and realign care. They have published a Commissioning Framework and required ICBs to develop 3-year plans to cease sending people to distant or outdated inpatient services and are working with the Greater Manchester ICB re oversight of The Priory Cheadle. The DHSC acknowledges concerns about mental health service funding, reliance on independent providers, and availability of specialist units. They highlight existing initiatives to improve patient flow, localise care, and ensure quality regardless of provider.

Noted (AI summary) The RCN acknowledges the report and highlights its learning resources for nurses and the importance of safe staffing levels, referring to external reports and standards, but does not comment on the performance of individual nurses or actions it will take.

Noted (AI summary) HSE explains its decision-making process regarding the investigation and clarifies its Incident Selection Criteria. While the suggestion to specifically name 'paraplegia' in the ISC will be considered, HSE states they are unable to take further action to change procedures, as their focus is shifting to risk-based selection.

Noted (AI summary) NHS England acknowledges the concerns and explains that interstitial lung disease is listed as a side effect in relevant resources. They suggest the coroner direct concerns about nilotinib and guidance to the MHRA. They also note work is being done nationally to share learnings from PFD reports. The MHRA has added the side effects experienced by Mrs. Mclaughlin to the Yellow Card database and requested the BNF editorial team consider including interstitial lung disease as a separate side-effect term in the nilotinib drug monograph; this will be included in the January 2025 online updates of BNF and BNFC.

Noted (AI summary) The ICB and Trust are jointly addressing bed pressures through intensive support to acute ward teams, transformation of crisis services including mental health triage, and review of rehabilitation and supported living settings. The ICB is also commissioning additional beds in the private sector. The Trust has reviewed and updated fire evacuation and AWOL policies, adding a flowchart to the pan-London policy, publishing the revised policy, issuing it to clinical service lines, undertaking AWOL drills, and creating a short scenario video. The learning will be shared via an internal learning bulletin. The DHSC acknowledges the concerns about mental health bed capacity and outlines the government's commitment to improving mental health services and suicide prevention. It states that the local NHS bodies will respond to the concerns about local mental health bed capacity directly.

Noted (AI summary) NHS England highlights increased access to CYPMH services, with 758,000 children and young people receiving support in the 12 months to January 2024. They cite a 46% increase in the CYPMH workforce since January 2019 and mention the NHS Long Term Plan's ambition for 100% access to specialist support. They also note discussion of all PFD reports by a working group. The DHSC acknowledges concerns about long waiting times for assessment and treatment in children and young people’s mental health services, and the importance of early intervention and support. They highlight the government's plans to increase mental health staff and improve access to services, and state NHS England will address concerns about the “keeping in touch team”.

Noted (AI summary) Supreme Care Services Ltd has reviewed all service users' pendants and undertakes weekly checks, reporting faults to the telecare provider and local authority. They also recommend clear flowcharts from the telecare provider and local authority on actions to take when equipment is faulty. TEC Quality describes the TEC Services Association's role as an independent industry expert and the Quality Standards Framework (QSF) used to audit service providers. They advocate for commissioners to specify the QSF in tenders but do not indicate specific actions taken or planned in response to the report.

Noted (AI summary) NHS England explains the NHS Pathways triage system and how it handles repeat calls, noting that ambulance services have local procedures for managing duplicate callers, including a geofence and other differentiating factors. They also highlight the use of the 'what3words' function to support location identification. West Midlands Ambulance Service explains their call taking protocols, addressing how they manage duplicate/repeat calls and clarifies the circumstances surrounding the delayed ambulance response, attributing it to significant hospital handover delays. They state the ambulance crew initially went to the kidney treatment center because they were unaware Mr. Fray had returned home.