2024

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.

Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.

Noted (AI summary) Stockport Council has permanently affixed reflective panels and tape to barriers in parks, including Alexandra Park (completed November 21st, 2024), and will complete remaining work by March 31st, 2025. They also audited lighting and found it compliant with BS5489 standards, and will do remedial work by March 31st, 2025 if needed. The Department of Transport states that the matter of barrier visibility is the responsibility of the local highway authority (Stockport Metropolitan Borough Council). They provided references to relevant guidance and legislation.

Noted (AI summary) NHS England states that Stockport NHS Foundation Trust plans additional weekend lists to reduce Stress Echocardiogram waiting times and hopes to achieve a 6-week standard by 31st January 2025. NHS England is not developing an MR angiogram service at this stage. Stockport NHS Foundation Trust plans an additional 20 weekend lists for Stress Echo to clear the backlog by 31st January 2025, aiming to achieve a 6-week standard for all patients. The Trust is also reviewing CT Coronary Angiogram service provision as part of its service development programme for next year. DHSC acknowledges the concerns but states that the procurement of diagnostic equipment falls under the responsibility of the trust and NHS England, who are better positioned to respond.

Noted (AI summary) NICE acknowledges the concerns raised but does not consider any actions from NICE would address the issues. East Kent Hospitals is reinforcing the Acute Abdominal Pain Pathway (AAPP) through monthly teaching sessions and case discussions. The AAPP document includes updated patient risk assessment, and the Hospital Discharge and Criteria to Reside Policy was updated to include a checklist for self-discharge. NHS England states that the concerns are local issues for the Trust to address, but that regional colleagues are engaging with the ICB and NHS England will review the Trust's response; also describes national work on PFD reports.

Noted (AI summary) The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level. NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care.