2025

Action Planned (AI summary) Dementia UK has been raising awareness of safe laundry product use through their "Keeping safe at home" leaflet and actively engaging with the UK Cleaning Products Industry Association (UKCPI) to support their safety awareness campaign, ensuring it supports people with dementia and their families. Defra will consider improvements to consumer protection measures and review detergents regulations, engaging with the detergents industry to consider voluntary safety measures addressing the coroner's concerns. They have also made the Office for Product Safety and Standards aware of the case. RoSPA will deliver a national social media campaign and develop practical guidance for carers on safe chemical storage by Q4 2025/26. They will also engage with manufacturers and regulators to improve packaging and warnings, advocating for safer practices.

Action Planned (AI summary) Leeds City Council has commenced a review of their process for attending incidents and implementing temporary repairs, including utilizing a new computer monitoring system (AMX) to track temporary repairs and monitor progress to permanent repairs. They will also undertake detailed assessments at other locations with defects and implement solutions when practicable.

Action Planned (AI summary) Nottinghamshire Police has revised its policy on s.136 detentions and will consult with EMAS regarding implementation. It will explore extending the hours of the Street Triage Team (STT) until 0300hrs, subject to collaboration with NHS partners. The force agrees that the concerns about mental health services for dual diagnosis is not a matter for them. EMAS will revise its policy on s.136 detentions and provide mandatory training for all frontline staff. It will engage with commissioners to advocate for service development to address the gap for patients with dual diagnosis (mental health and substance misuse) and strengthen guidance around dual diagnosis in training. National Highways will undertake a Road Restraint Risk Assessment Process (RRRAP) to assess the need for VRS or other mitigations at the specified location. They will complete the assessment before 31 December 2025 and report findings by 13 February 2026.

Action Planned (AI summary) NHS England states that documenting communication between community midwives and hospital staff is standard via Electronic Patient Records; SPR will be rolled out in maternity care first. Concerns have been shared with maternity and neonatal units across the East of England region, and they have been reminded to record discussions on electronic records where available; all reports are discussed by the Regulation 28 Working Group. RCPCH acknowledges concerns about documenting calls from midwives to hospital teams and supports the use of the NHS number as a single unique identifier. They are actively supporting the rollout of Martha’s Rule, an inpatient safety initiative, and learnings from the pilot could in future be applied in the community setting.

Action Planned (AI summary) NHS England is advised that the involved GP surgery has taken learnings from Myles’ death, including improved processes for managing patients with learning disabilities and autism and reminding staff of the importance of accurate documentation. NHS England has also been engaging with NHS West Yorkshire Integrated Care Board on the concerns raised. Dalton Surgery has implemented a range of actions including Oliver McGowan mandatory training, Practice Protected Time meetings, and enhanced communication. The practice has developed a detailed action plan with auditable evidence and clear timescales, working with ICB colleagues. CQC has been in contact with Dalton Surgery to establish the full circumstances and request information about their planned actions; they have received an action plan. CQC will use the Oliver McGowan Code of Practice when considering whether providers are meeting regulatory requirements; bespoke upskilling sessions will be run for inspection teams. The CQC has contacted Calderdale and Huddersfield NHS Foundation Trust and will receive information about actions taken to prevent a reoccurrence. The CQC will also use the Oliver McGowan Code of Practice when considering whether providers are meeting training requirements and upskill inspection teams on the mandatory training.

Action Planned (AI summary) ADEPT will share relevant research, learning, best practice and technical guidance relating to thin surface treatments and road safety with its members, working with the DfT and RSTA. The RSTA reviewed specifications and processes with members and will discuss concerns raised by the Coroner relating to asphalt preservation systems with National Highways, providing an update after the meeting. The DfT will work with ADEPT to raise awareness of the "early life effects" issue among local highways authorities and will review/update the 'Well Managed Highways Infrastructure: A Code of Practice' to address the report's recommendations, considering signage for thin surface treatment locations.

Action Planned (AI summary) HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to staff to ensure a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision.

Action Planned (AI summary) The NPCC highlights the importance of personal responsibility on license holders for the security of firearms. The NPCC commenced delivery of an additional two-day course for Firearms Licensing Enquiry Officers focusing on domestic abuse, family turmoil, mental health and wellbeing in June 2025. The Home Office alerted all police forces to the issue of information sharing regarding shotgun license holders, and it is possible for police to check if an individual is a firearm or shotgun certificate holder. They will also engage with the DHSC directly regarding police access to health information. The Department will explore broadening access to relevant medical information of others residing at licence-holders' addresses and engage with GP representatives. They will work with them to ensure that operational guidance relating to the existing Digital Firearms Marker policy remains fit for purpose and considers ongoing learnings.

Action Planned (AI summary) The NFCC is working with Humberside Fire and Rescue Service to share learning from the incident via the NFCC Organisational Learning platform. The letter also states that the Secretary of State at the Department of Health and Social Care (DHSC) will be made aware of comments concerning rights of access for ambulance personnel. The National Police Chiefs Council has established a group to review and track coroner’s reports relating to the application of Right Care, Right Person, and any learning will be disseminated and policy amended as needed.

Action Planned (AI summary) NICE will consider updating the recommendations in its guidelines on inducing labour (NG207) and intrapartum care (NG235) regarding the frequency of clinical assessments before active labour, and the use of combination therapies for pain relief.

Action Planned (AI summary) NHS England is developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems, to ensure all required information is available to staff. It highlights existing systems, including the National Care Records Service, and discusses reports received by the Regulation 28 Working Group.

Action Planned (AI summary) The Trust is implementing the National Pressure Injury Screening Tool, and reviewing the SSKIN care bundle and repositioning documentation; working with EPIC National Team to review current output documents provided to Coroners to improve clarity, structure, and usability of these records.

Action Planned (AI summary) GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.

Action Planned (AI summary) The JRCALC will review the existing abdominal pain and vascular emergencies guidelines, to include additional terminology and advocate the use of the Aortic Dissection Detection risk score.