2025

Noted (AI summary) NHS England expresses condolences and explains the context of shared decision making and risk assessment, referring to existing national guidance and tools. It states that commenting on the specific clinical decision is outside of NHS England's remit, and refers to the Trust's response regarding handover communications. The Trust has rolled out mandatory consent training and has a focused approach in place to support safe and timely transfers. A daily meeting has been established to identify patients who can be stepped down from ICU care to ward level care. The response acknowledges national guidance from NICE and the British Geriatrics Society and states that Stockport NHS Foundation Trust has taken steps to improve information and training relating to shared decision making and consent. Martha's Rule is being expanded to all acute inpatient sites. Medical examiners have been implemented on a statutory basis.

Noted (AI summary) • NHS England has produced a national framework and operational guidance for autism assessments. • The operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments. • Birchills Health Centre reviewed J.A’s case in a clinical meeting on 19.01.2023 and more recently on 02.02.2026 as part of their child protection meeting. • Birchills Health Centre identified that more comprehensive record keeping including clearer details of fluid intake should be recorded in assessing any child with risk of dehydration. • Birchills Health Centre had a presentation on identification of dehydration in children to help remind clinicians on most effective ways of assessing hydration status.

Noted (AI summary) CGL Ealing RISE will provide leaflets and website information about consent and confidentiality at the commencement of treatment, addressing how families can share concerns without breaching confidentiality, as well as an alternative point of contact in the organisation. The response explains Change Grow Live's confidentiality policy, including when information can be shared and how families can stay involved while respecting privacy.

Noted (AI summary) NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. However, the publishers of the CKS will make some changes to ensure it is clear where ECG monitoring is required. The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary care clinicians and across relevant networks, and support service links with colleagues.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns about district nurse numbers but states the responsibility lies with local Integrated Care Boards and NHS trusts, while mentioning a forthcoming 10 Year Workforce Plan.

Noted (AI summary) NHS England highlights existing national guidance and safety alerts on anti-ligature measures, and the North London Mental Health Partnership's incident response with recommendations, and will continue to engage with local teams for updates. The organisation also notes that all reports received are discussed by the Regulation 28 Working Group. The Department acknowledges the concerns and references existing guidance from the Care Quality Commission and NHS England on anti-ligature measures, as well as ongoing work via NHS England's mental health inpatient quality transformation programme and the national Suicide Prevention Strategy.

Noted (AI summary) The North East and North Cumbria Integrated Care Board acknowledges the concerns, noting the existing systems for patient record sharing via the Great North Care Record and the responsibility of medical professionals within multidisciplinary teams. They also refer to NHS England guidance on outpatient services. Moorbridge School has conducted a thorough review of their practices related to information sharing and safeguarding and will revisit and reinforce staff understanding of these policies through annual refresher training. 49 Marine Avenue GP Surgery acknowledges shortcomings and will strengthen communication with secondary care, improve multidisciplinary communication, and review safeguarding procedures. They will also implement new guidelines for monitoring, supporting families, and provide staff training in eating disorder management. The Trust has implemented a restructure within the Dietetics Service, introduced mandatory training for staff on safeguarding children, and will discuss information sharing between primary and secondary healthcare at the NENC GP Provider interface group by October 2025. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue and aim to have a Single Patient Record processing information by 2028.

Noted (AI summary) RCEM highlights existing standards requiring paediatric early warning scores, results from national audits, involvement in designing a revised paediatric early warning score, and advocacy for better staffing and resources. The RCN states it is not the regulator for nurses and has no remit to address the concerns, but offers learning resources and highlights its work on the National Early Warning System (NEWS2) Observations Tracking Programme and collaboration with RCPCH on emergency care standards. The Trust has implemented training and induction enhancements, updated the Emergency Department Nurse in Charge checklist, mandated completion of an ED Paediatric Discharge Checklist, and is undertaking ongoing monitoring and training to improve standards of practice. The RCPCH is in the process of updating its Facing the Future Standards for Emergency Care, to be published later in 2025, which will clarify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.