2024

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. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE. 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. 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.

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.

Noted (AI summary) NHS England has asked ambulance trusts to confirm compliance with NHSE guidance and has escalated the issue with the 25-C codes to the International Academies for Emergency Dispatch for rapid resolution. AACE states that the primary ownership of the concerns regarding 999 call categorisation lies with NHS England and that they have liaised with NHS England to ensure the matters of concern are being considered.

Noted (AI summary) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.

Noted (AI summary) NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to Prevent Future Deaths are discussed by the Regulation 28 Working Group.