2024

Noted (AI summary) NICE acknowledges the coroner's concerns regarding arterial thrombus but clarifies that existing guidance focuses on venous thromboembolism and does not cover arterial prophylaxis. NICE will continue to monitor new evidence in this area.

Noted (AI summary) Kirklees Council amended its Housing Assistance Policy to reflect that they may remove adaptations should they pose any risk to any persons in the household. The council will raise a Safeguarding Adults Review (SAR) referral to help identify any learning for future purposes. Radis Community Care states that they generally do not remove minor aids and adaptations once fitted, as it is the responsibility of the homeowner, landlord or tenant to remove them. Exceptions are made for re-usable items or safeguarding concerns.

Noted (AI summary) GTD Healthcare has implemented changes to the standard templates used by Assistant Practitioners and provided hard copies to clinicians for use during IT issues. They have also implemented safeguards to ensure appointments with Assistant Practitioners are booked after a triage by a registered clinician and have audited and reviewed their prescribing practices. The DHSC acknowledges the concerns, states they fall under the provider's remit, and notes that NHS England and the CQC have been contacted to address them. It provides context on supervision guidance for PCNs but offers no concrete actions.

Noted (AI summary) The Trust defends its advice to contact the police due to concerns about violence and aggression. Learning from this incident will be shared at various Trust meetings. The Trust updated its Food, Nutrition and Hydration Policy in November 2024 and is consolidating nutritional assessments into one section of the electronic nursing record. They have also revised incident management processes and implemented a new policy for post-incident debriefs.

Noted (AI summary) The Ministry of Defence expresses sympathy and highlights existing mental health support for service personnel and veterans, stating that the deceased received treatment for addiction issues before discharge, but requests to be engaged earlier in inquests where service history is relevant.

Noted (AI summary) NHS England acknowledges concerns and outlines existing oversight mechanisms, offering support to connect TCT's clinical team to specialists within the NHS and supporting TCT in connecting within the local integrated care system to improve flow to clinical appointments. CQC states that The Children's Trust (TCT) have strengthened their frequency of monitoring policy and increased their audits of the implementation of this policy; have a Frequency of Monitoring Policy in place since July 2022 which continues to be reviewed and updated. CQC have seen evidence of a strengthened learning culture at TCT through inspection and routine engagement conversations. The DHSC acknowledges the concerns raised in the report and states that they have sought assurances from the CQC and NHS England that responses are being prepared to address concerns respective to each organisation. They highlight ongoing monitoring by the CQC and clarify commissioning responsibilities. The Children's Trust has revised its Frequency of Monitoring Policy, enhanced clinical governance frameworks, and strengthened integration with NHS services following the death of Mia Gauci-Lamport.

Noted (AI summary) Surrey County Council is preparing a communication to all Surrey education providers to clarify that there is no financial threshold for requesting an EHCNA, reinforcing the statutory position under the Children and Families Act 2014. The Department for Education acknowledges the concerns, highlights existing guidance on safeguarding and EHCPs, and notes ongoing monitoring of Surrey County Council's SEND arrangements, keeping the safeguarding guidance under review.

Noted (AI summary) NHS England acknowledges the concerns about periacetabular osteotomy (PAO) procedures and states that it is a specialist procedure that should be undertaken only by clinicians with the requisite training and experience. They defer further comment on the specific concerns to Barts Health NHS Trust and suggest the coroner refer to the Royal College of Surgeons or the British Orthopaedic Association for further information.