2025

Action Planned (AI summary) The government launched a Road Safety Strategy including a consultation on mandating vehicle safety technologies covered by UN R158. The UK will raise the possibility of including goods vehicle trailers in the scope of UN R158 at the next UNECE working group meeting.

Action Planned (AI summary) YAS will send a clinical alert reinforcing that known high-impact risks, such as swallowing or choking risk, should be explicitly raised at handover where they are clinically active or present a foreseeable risk of harm. Learning from this case will be shared through clinical forums and with system partners. The hospital implemented an immediate action ensuring patients in the Emergency Department are not given food without the oversight of a registered nurse. The Trust has a Standard Operating Procedure (SOP) for Sip Testing in place along with training.

Action Planned (AI summary) • The Trust is developing a new private care protocol to guide clinicians on how to approach circumstances when a patient is accessing care from a private healthcare provider. • The protocol will operate within the existing policy framework, linked to existing policies and procedures for information sharing and record keeping. • Work to develop this new protocol is underway and will be completed by the end of this month, applying to new and existing patients.

Action Planned (AI summary) • The approach to monitoring service users following changes to antipsychotic medication has been strengthened and is being implemented, with full standardisation across all relevant services to be completed by 1 March 2026. • Any request for enhanced monitoring following medication changes is now formally logged and reviewed at the first daily multidisciplinary planning meeting. • The process includes a structured clinical discussion to confirm the level of risk and the intensity of monitoring required, clear allocation of responsibility to a named clinician, and formal recording within the clinical diary system.

Action Planned (AI summary) The ENA has convened member companies to improve arrangements following the death. They plan to produce industry guidance on health and safety risk assessments for low-hanging overhead lines and promote innovative monitoring technologies by September 2026.

Action Planned (AI summary) NICE acknowledges the difficulty of recognising sepsis in children and highlights existing guidance and screening tools. They are planning to update their guidance on paediatric sepsis in 2026, considering adapting the current 'traffic light' system to one based on NPEWS.