2024

Noted (AI summary) NHS England is undertaking training and upskilling of healthcare and prison staff in the London region. They are also reviewing service specifications and will use learning from the case to strengthen requirements around assessment and management of long-term conditions. HMPPS acknowledges the concerns and refers to ongoing work led by NHS England to improve awareness of sickle cell disease and other long-term conditions, stating their commitment to working collaboratively with healthcare providers.

Noted (AI summary) The Welsh Ambulance Services University NHS Trust acknowledges concerns about ambulance delays and the MPDS system but states it is not the primary authority to take action, offering to meet to discuss the response in more detail and welcomes suggestions for actions they might take with partners.

Noted (AI summary) The HSE is publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. They are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks. The Worktop Fabricators Federation provides a 'state of the art' positioning statement on silica dust risks associated with quartz worktops, highlighting the need for safe working environments and suggesting potential market controls. The Agglomerated Stone Manufacturers Association highlights existing efforts to promote safety and calls for governmental involvement, suggesting clear rules and/or a licensing program for fabricators. MHCLG is requesting an extension and states that the concerns fall within the remit of the HSE, offering to provide a formal response explaining the limitations of MHCLG's policy remit. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE.

Noted (AI summary) West Yorkshire Police has implemented changes including a quarterly review by the DCI at Professional Standards, an annual review by the Head of Professional Standards, and quarterly meetings between the senior leadership team at Professional Standards and senior leaders at the IOPC. The IOPC acknowledges the concerns and highlights existing guidance and the ongoing Transformation Programme to improve timeliness, but states that primary responsibility for welfare rests with the officer's force.

Noted (AI summary) NHS England acknowledges the concerns and will review UKHSA's response, while highlighting existing IPC guidance aligning with 'The Green Book' and planned discussions by the Regulation 28 Working Group. The UKHSA expresses condolences and explains its role in iGAS notification and investigation. It states that it has no plans to amend the 'Green Book' guidance regarding alcohol wipes prior to vaccinations, as the matter falls outside of its remit. Browney House Surgery will use the case as a learning exercise, staff will attend Infection Prevention and Control courses, enroll into an Injection Administration Training course and follow local and national guidance. DHSC has determined that UKHSA is better positioned to address the issues raised in the report, as responsibility for guidance on immunization procedures lies with them.