2024

Noted (AI summary) Amicus Health will flag high-risk patients prescribed medications for closer monitoring with regular reviews and shorter prescriptions. They have eliminated non-auditable messaging systems for clinical information to ensure transparency and accountability in prescription management. The Royal Pharmaceutical Society acknowledges the concerns raised. They will consider how to raise awareness of these important issues through future communications and engagement with the wider pharmacy sector and will raise these issues with colleagues at the professional and representative bodies for pharmacy. Pharmacy2U will monitor inbound contact channels to ensure prompt responses. The superintendent pharmacist has discussed the case with the senior clinical management team and will continue to work internally and with healthcare colleagues in other parts of the NHS.

Noted (AI summary) Norfolk and Suffolk NHS Foundation Trust states that the NHS 111 Mental Health Option telephone support line is not commissioned to provide medication prescriptions and refers to its Management of Medicines Policy; it also says it has implemented a new Standard Operating Procedure for mental health liaison teams within acute hospitals. DHSC states that the NHS England National Specialty Advisor for Mental Health Pharmacy will write to mental health Chief Pharmacist colleagues across England requesting that they ask local systems and prescribing committees to review their local mental health prescribing policies.

Noted (AI summary) The Department for Transport will examine what more could be done to ensure the roadworthiness of tractors, trailers and coupling devices and will investigate how best to raise awareness of the DVSA's published guidance on maintaining roadworthiness and vehicle loading, as well as of the existing voluntary trailer maintenance scheme. The NFU provides information and guidance to its members via its website, Business Guides, the British Farmer and Grower magazine, and electronic newsletters, and regularly highlights the importance of tractor and trailer maintenance when communicating with its members. HSE outlines its role as Britain’s national regulator for workplace health and safety and highlights that the health and safety legislative framework and associated guidance is sufficient and clear in its requirement to use equipment suitable for the task that is maintained in a safe condition. The AEA and BAGMA would support proposals for change from the Department for Transport including extending mandatory roadworthiness testing to vehicles travelling below 25mph and requiring failsafe breakaway systems on all trailers.

Noted (AI summary) NHS England acknowledges the concerns and provides context on the Summary Care Record (SCR), the Royal College of Emergency Medicine (RCEM) guidance, and the National Record Locator (NRL), and states reports are discussed by the Regulation 28 Working Group. NHS Dorset will enforce the use of the Dorset Care Record in line with contractual commitments in 2025/2026 and will monitor progress of the issue directly via their Corporate Risk Register. They will also share the Regulation 28 Report with NHS partners and wider system partners at the Pan Dorset Mortality Group.

Noted (AI summary) NHS England acknowledges concerns about smoke-free policy application in mental health settings but refers to existing NICE guidance and states that individual NHS Trusts are responsible for local implementation. They also note that regional colleagues are seeking assurances from the relevant system regarding local arrangements. NICE acknowledges the concerns but states that the issues raised regarding national policy contradictions are outside their remit and best addressed by NHS England and the CQC. They highlight their guideline NG209 on tobacco dependence. The Department of Health and Social Care acknowledges the concerns regarding the smoke-free policy's impact on mental health inpatients and refers to the legal requirement for smokefree hospital premises. They expect NHS organisations to support patients who smoke through cessation measures or safe leave arrangements, and note that NHS England will address concerns around national guidance.

Noted (AI summary) Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act.

Noted (AI summary) The DVLA acknowledges receipt of the coroner's report and extends condolences, stating that a full response, agreed with the Department for Transport, will be sent by the Secretary of State for Transport. The Department for Transport acknowledges the concerns, explains the driver licensing renewal process for those over 70, and mentions a 2023 call for evidence on driver licensing for people with medical conditions, the analysis of which is ongoing, with potential changes to the legislative framework to follow.

Noted (AI summary) NHS Bolton expresses condolences and provides clarification on their existing radiology request procedures, stating that radiologists determine the appropriate scan modality based on the Ionising Radiation Regulations and clinical guidelines and that PE exclusion follows a standardized pathway. The RCR highlights a joint RCR/Royal College of Emergency Medicine guideline on diagnosing thoracic aortic dissection, published in January 2024 and currently undergoing a minor review, which aims to provide consensus on CT scanning criteria in emergency departments.

Noted (AI summary) The UKHMA engaged with stakeholders and communicated findings to members, and brought the MAIB report to the PMSC steering group. They also proposed the inclusion of guidance in the GTGP, which is expected to be reviewed around Q3 2024. British Marine helped produce and publish the HSPV code in 2010, revised in 2019, and made its use a requirement of membership for operators carrying out this type of activity. The RYA has delayed review of its "Small High Speed Passenger Vessel Voluntary Code of Practice" awaiting MCA legislation, and envisages releasing a revised edition soon after the MCA Sport and Pleasure Vessel Code is finalized. The BPA acknowledges the concerns and has corresponded with the MAIB regarding guidance, stating the MCA should lead this. The BPA has offered to promote and amplify guidance, but is not insured to set safety-critical guidelines itself. The British Standards Institution acknowledges the concern regarding BS EN ISO 11591 but clarifies its role as a facilitator for expert committees to develop standards, not to interpret or regulate them; BSI will refer the concerns to the relevant technical committee. The Department for Transport states that the MCA is prioritising an updated Sport or Pleasure Vessel Code, currently under public consultation. The MCA has also been tasked to commission an anthropometric assessment of small high-speed passenger craft safety, with results expected in late spring/early summer 2026. Associated British Ports acknowledges the concerns but states that monitoring AIS tracks of vessels and intervening in their operation would be very challenging, require dedicated resources, and may not materially increase the safety of harbour users, also noting the limitations of their powers and resources for policing vessels. The MCA is working on an updated Sport or Pleasure Vessel Code, informed by the MAIB Investigation Report, which is currently undergoing public consultation. They have also begun procurement for an anthropometric assessment of small high-speed passenger craft safety, with a report expected in late spring/early summer 2026 to inform future code revisions and guidance. Red Bay Boats Limited has instructed Scot Seats to test seats to meet HSC 2000 standards; they recommend installation of Scot Seats where possible; they will not accept any commissions in the thrill-seeking market; and feel that sea safari craft should not exceed 25 knots. The UKMPG states it supports information sharing but doesn't develop guidance and believes this should be led by the MCA. They will support actions suggested but this must be led by the MCA with industry input.