2025

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.

Noted (AI summary) The Complex Spine Clinic confirms that no prescriptions were issued to the patient after receiving a letter from their psychologist suggesting a potential risk of suicide.

Noted (AI summary) The doctor reflects on the consultation, acknowledges the concerns raised, and outlines their understanding of critical limb ischaemia and its management. They state that they will continue to stay updated reinforcing knowledge and learning. The surgeries plan to hold a learning event to review the presentation of patients with peripheral vascular disease and differential diagnosis of ‘foot and lower limb pain’. They will also review the presentation and management of similar lower limb pain, possible ischaemia, in weekly clinical meetings.

Noted (AI summary) The trust clarifies that no serious incident investigation was undertaken and no follow-up appointment was made in the fracture clinic as no fracture was identified. They describe current protocols for wound management including regular team meetings and monthly masterclass sessions.

Noted (AI summary) This is a data report from Rotherham NHS Foundation Trust on inpatient falls, including falls rate, bed days, and moderate or above falls, with comparisons to national benchmarks. Rotherham NHS Foundation Trust has assigned falls champions on each ward and healthcare assistants on every shift to ensure lying and standing blood pressures are completed, added a mandatory question to the inpatient discharge summary about falls/VTE/pressure ulcers, and included Datix reporting information in the induction for temporary staff. This is a template document for Rotherham NHS Foundation Trust's Care Group 1 Nurse in Charge handover checklist, to be completed at each handover to ensure key information is communicated and actions are taken. This is a template document for Rotherham NHS Foundation Trust's Care Group 1 (Medicine) safety huddle log, to be completed three times daily to review patient safety, safeguarding, staff wellbeing, and other key issues.

Noted (AI summary) The First Minister for Wales acknowledges concerns about ambulance patient handover delays at Cwm Taf Morgannwg University Health Board and outlines the Welsh Government's governance and escalation processes for NHS organisations, noting that all health boards are in escalation for urgent and emergency care.

Noted (AI summary) The practice has amended its process for new baby registrations, including removing the 'unregistered babies' folder and updating the Docman system to allow electronic rejection of incorrectly sent correspondence. NHS England acknowledges the concerns about the NHS Pathways algorithm and details its function. It highlights existing access to clinical support for health advisors and refers to work by the Regulation 28 Working Group. The trust has already taken several actions including auditing the call, sharing learning through various channels, and providing training to staff. They have also reviewed and amended the NHS Pathways cardiac arrest algorithms following a previous case. The CQC contacted the provider, Unity Health, who confirmed they reviewed their processes and implemented a new system for creating a new profile when they are notified about a birth. They flagged this issue with the ICB and will be sharing details of this incident with the CQC’s Primary Care inspection teams.