2025

Noted (AI summary) Islington Council expresses condolences and provides background on the inquest hearing, including limitations on evidence presented, and includes details of their income and expenditure assessment process for housing applicants.

Noted (AI summary) Resuscitation Council UK provides context on its neonatal resuscitation courses (NLS, OH-NLS, ARNI) and states that the NLS approach and algorithm adequately address the potential causes of non-response during newborn resuscitation. The Y&H Neonatal ODN has regional guidelines on surfactant administration and provides education sessions, and has written to all neonatal units in their network and other Neonatal ODNs to share these guidelines and draw attention to the Coroner's concerns. BAPM acknowledges concerns about LISA procedures and reversible causes of cardiac arrest, and while stating that universal consultant approval for LISA is not necessary, they plan to send a safety alert to members and stakeholders drawing attention to relevant recommendations in their Frameworks for practice. The Trust updated its risk register to include risks related to service provision, staffing, and protocols, and are working with the ODN and Commissioners. They also detail actions taken in response to the concerns raised, including changes to the SJUH designation and mitigations for risks due to lack of centralisation. RCPCH acknowledges concerns regarding LISA guidelines and reversible causes of cardiac arrest but defers to BAPM and RCUK for specific guidance and actions, noting they expect members to follow Resuscitation Council UK guidance. The Department acknowledges the concerns regarding maternity services at Leeds Teaching Hospitals NHS Trust, particularly staffing levels and the delay in centralizing services due to the New Hospital Programme's revised schedule, but defers to the Trust for specific responses and emphasizes existing duties for Trusts to maintain adequate staffing. This is an exhibit referenced by another response. It is a LISA checklist.

Noted (AI summary) The Trust reconfigured out-of-hours radiology reporting, separating ED and inpatient reporting across hospital sites starting September 1, 2024, and delivered an educational session around aortic dissection, though they maintain that the abnormality was very subtle and difficult to identify. The DHSC acknowledges concerns about insufficient radiologists at Good Hope Hospital and refers to the responsibility of individual NHS Trusts to determine staffing levels and the upcoming 10 Year Workforce Plan, deferring to the Trust for specific responses.

Noted (AI summary) The CAA has adopted updates to Acceptable Means of Compliance to CS-27 and CS-29 relating to rolling contact fatigue in critical bearings and initiated rulemaking projects to clarify the airworthiness status and life limits of critical parts and ensure the removal of defective critical parts from service. They will also engage with international counterparts to harmonise approach to critical bearing design and certification. EASA acknowledges the concerns raised in the Prevention of Future Death Report, referring to their assistance in the AAIB safety investigation and internal procedures for addressing safety recommendations. They state that they are considering introducing new AMC to CS 29.927(a) (Additional tests) to clarify the need to support inspection intervals and retirement times with appropriate directly applicable data, but believe the existing framework is adequate.

Noted (AI summary) The Welsh Government outlines its role in setting the strategic context for health services and holding NHS organisations accountable, noting that all health boards are in escalation for urgent and emergency care. They mention providing additional funding to Betsi Cadwaladr University Health Board and supporting improvement programs, but do not commit to specific changes in response to the report.

Noted (AI summary) Middlesbrough Council will ensure their mental health service receives refreshed communication regarding section 136 guidance, and the circumstances relating to the Regulation 28 report. This will be flagged within the Multi-Agency Mental Health Legislation Operational Group to determine the need for further awareness and training among wider partners. Redcar and Cleveland Borough Council will recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the concerns identified through Mr Bradley’s inquest. They reiterate the use of the Crisis Assessment Suite at Roseberry Park as the appropriate place of safety. Stockton on Tees Council will bring TEWV's Section 136 policy to the Mental Health Legislation Operational Group to consider further education for Cleveland Police. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care. Hartlepool Council will give consideration to further education and awareness raising within Cleveland Police regarding the use of Section 136 powers. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the inquest's concerns. The ICB acknowledges the concerns regarding mental health safeguarding for intoxicated individuals, explains existing crisis services, and states they have no plans for a specific holding facility. They note that the crisis team was not contacted in this specific case, so they can't comment on the potential outcome. Tees, Esk and Wear Valley NHS shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025 to ensure awareness of the Report and best practice. This report has also been shared with Crisis Teams. The Department of Health and Social Care liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding directly. They also mentioned Cleveland Police began to implement the Right Care Right Person approach in 2024, and committed £26 million in capital investment to support people in mental health crisis.

Noted (AI summary) Durham Constabulary's Deputy Chief Constable states that a full review of the case and police actions was undertaken, with the outcome and actions attached to the response. The Police and Crime Commissioner expressed condolences and noted that a review by Durham Constabulary didn't highlight significant failings but resulted in two points of organisational learning and recommendations. The commissioner will monitor the 'Right Care Right Person' model. The College of Policing has contacted Durham Constabulary, who have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. Durham Constabulary will implement recommendations aligned with the National Toolkit for Right Care, Right Person (RCRP), aiming for full implementation by mid-July 2025. These include a review of police systems for further intelligence, supervisor review, and immediate escalation to the Supervisor on a second call about the same person within a 12 hour period.