2024

Noted (AI summary) National Trading Standards explains their remit and states they do not have enforcement powers in this situation, recommending the Coroner contact other agencies. The HSE outlines the duties of letting agents under the Health and Safety at Work Act, but notes their undertaking is unlikely to extend to areas outside the property or managing tenant behaviour. They suggest the letting industry may wish to consider passing on information about risks beyond their direct undertaking. The agency will reinforce tenancy agreements to prohibit access to non-designated areas like roofs, issue written warnings for violations, and collaborate with Islington Council on tenant safety procedures.

Noted (AI summary) Hotpoint states it will support the LFB/AMDEA initiative of digital identification and comply with any future industry-wide regulatory requirements. It will also work with government policy makers, regulators, fire services, manufacturers and other stakeholders to continue to raise the bar for appliance product safety in the UK. AMDEA acknowledges the coroner's concerns and states its commitment to collaborating with stakeholders to enhance product safety. They also note that fire incident data for key appliances is collated annually to identify trends and inform safety improvements. BSI acknowledges the coroner's concerns and explains its role in standardization. The CPL/61 committee considered the request to improve standards for condensate pumps and filters but needs more information regarding the fire investigation before a decision can be made. North Yorkshire Council, as primary authority for Hotpoint, states that testing was conducted on the part in question and that it passed all tests. They have arranged for further testing and state Hotpoint will comply with any changes in the law. The National Fire Chiefs Council states that receiving information from manufacturers on replaced or recalled parts is not within their remit. They support the single recall register and advocate for manufacturers to share risk assessments when patterns of faults are found. OPSS is seeking an update from BSI on the progress of a pilot project trialing a fire-resistant marking approach to enable identification of fire-damaged appliances and supporting their traceability. The Home Office acknowledges the report but states it cannot provide a specific response due to a lack of detail regarding which aspects of information management need to change. CTSI acknowledges the coroner's concerns and describes its role in consumer protection and its support for OPSS. It highlights the need for a national approach to product safety and consumer reporting mechanisms.

Noted (AI summary) The Department of Health and Social Care acknowledges the report and expresses condolences. They state that the Department of Education has oversight for child social care and is best placed to comment on the concerns raised. Social Work England acknowledges the coroner's concerns and is reviewing documentation and recordings from the inquest to determine if there are reasonable grounds to investigate any of the individual social worker’s actions, and will contact relevant parties to gather further information. NPAS will use footage from the incident as a case study/training tool to encourage Tactical Flight Officers to think beyond initial information in similar search scenarios, starting with the next training course on February 14th. The London Borough of Newham has re-evaluated internal policies and procedures and made significant changes and improvements, including a review of complaints, annual audits focusing on single parents with limited networks, and a review of the Supervision Policy, alongside MAGPIE and Praxis. An NRPF Plan template has been introduced following Child and Family Assessments, and the NRPF Panel Form has been embedded in their ICS system.

Noted (AI summary) NHS England notes the concerns about non-uniform hospital discharge notes and highlights the existing national guidance and role-based action cards. They state that Royal Papworth Hospital has improved processes for updating next of kin on patient transfers and that the Regulation 28 Working Group discusses reports to identify emerging trends. The DHSC acknowledges the concerns and refers to national statutory hospital discharge guidance, noting that individual trusts are responsible for their own discharge policies. They welcome the steps taken by the Royal Papworth Hospital NHS Foundation Trust around involvement of next of kin in patient transfers.

Noted (AI summary) HM Inspectorate of Prisons acknowledges the concerns raised and states that the issues are covered in their inspection criteria. They will keep the findings on file for future inspections of HMP Whatton and HMP Hollesley Bay. HMP Whatton will update their Induction policy to include a "late arrivals form" for prisoners when a normal induction cannot be facilitated, and has amended their local safety strategy to ensure prisoners are informed in writing when their CSRA levels change. HMP Hollesley Bay will seek POM attendance at local stability meetings where OCSAs are being discussed wherever possible.