2025

Noted (AI summary) NHS England acknowledges the concern and highlights its national role in providing guidance and support, specifically through Controlled Drugs Accountable Officers (CDAOs). The response notes that commissioning of services now lies with ICBs. An Opioid Reduction/Discontinuation Pathway is planned within the Community Musculoskeletal (MSK) Service, due for implementation in February 2026. The ICB Executive Committee has endorsed a proposal to scale up the Aegros Primary Care Network (PCN)-based model across the ICB. The Minister acknowledges the concerns about the lack of specialist services for managing dependency-forming medicines and outlines national initiatives, including NHS England's work and the MHRA's review of codeine. It also described actions being taken for those with substance use and mental health needs.

Noted (AI summary) The Royal Pharmaceutical Society acknowledges the concerns raised, explains their role versus the GPhC, and explains the complexities around medication supply and pack sizes. They will raise awareness of the report with other stakeholders and request further details of the case.

Noted (AI summary) The Trust has implemented measures to ensure staff are competent, including mandatory training checks and escalation procedures. They have also formed a Physical Health Task and Finish Group to review physical health provision on inpatient wards, piloted a Physical Health Secondary Care planning Cycle, and provided staff training. HMPPS published guidance on managing self-neglect in prisons in July 2024. They implemented a new booking tool for ACCT reviews in August 2024, introduced a new shift pattern for key workers in September 2024, and issued a Notice to Staff mandating ambulance calls for emergency codes. The Minister acknowledges the concerns and offers condolences, deferring to the Director General of Operations at HMPPS for a detailed response.

Noted (AI summary) The DHSC has a surveillance system in place to track changing drug markets and harms, including toxicology results from coroner post-mortem toxicology labs and implemented a structured process for assessing the threat posed by synthetic opioids and other drugs. DHSC has published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required. FRANK website has a page providing detailed information on when and how to use naloxone. The ACMD acknowledges the concerns about nitazenes in vapes and notes its existing reports and recommendations on the issue, including improved toxicology and testing, and improved information for health professionals and the general public; it will raise the concerns at an upcoming meeting.

Noted (AI summary) The CAA concludes that no change to the existing aviation safety regulation framework is currently required, given safeguards in place related to airworthiness and operational regulations, design and certification requirements and operator safety management systems; however, it will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks. The CAA concludes that no change to the existing aviation safety regulation framework is currently required, given safeguards in place related to airworthiness and operational regulations, design and certification requirements and operator safety management systems; however, it will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks. The DfT notes that ICAO has amended Annex 13 via SARP 5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated.

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.