2025

Noted (AI summary) NHS England is developing a Reasonable Adjustment Digital Flag to record information about patients, including if they are autistic or have a learning disability, and their reasonable adjustment needs. The RCEM highlights existing resources such as the Learning Disabilities Toolkit and involvement in the development of the ED version of the national paediatric early warning system (nPEWS). They feel unable to comment on inpatient care and state provision of learning disability nurses is outside their remit. CQC acknowledges the concerns but states that commenting on the specific guidance is outside of their regulatory scope. They are reviewing the case in line with their incident guidelines. The Trust is developing a Learning Disability Admission Checklist to provide prompts for staff in Emergency Departments and establish a system to record reasonable adjustments, planned for Quarter 3, 2025. RCPCH's revised Facing the Future: Emergency Care Standards will be published in Autumn 2025 and shared with relevant professionals, and will include a standard on EDs having a lead professional for CYP with complex needs and access to advice from a Learning Disability Liaison Nurse. The Department highlights the upcoming 10-Year Health Plan which will improve awareness of learning disability and autism within the health and social care system. It also references Martha's Rule which gives patients and their families the right to initiate a rapid review of their case.

Noted (AI summary) The council disputes the coroner's concern that its staff could not access records, stating that the records were available, and a review of care arrangements was carried out with awareness of the assessment. It also states that its Careline service acted upon learning from the events leading up to the deaths of Mr and Mrs Cleall.

Noted (AI summary) The Trust acknowledges bed availability challenges and mentions ongoing work to improve bed management and reduce out-of-area placements. They plan to prioritise inpatient strategy development with the Integrated Care Board and ensure adequate access to inpatient care is acknowledged through the Contract Management Board. The DHSC acknowledges the concerns, notes actions ICBs are required to take, refers to funding and initiatives to support mental health crisis care, and describes broader government commitments to suicide prevention.

Noted (AI summary) Dorset Council plans to implement a temporary traffic regulation order prohibiting certain turns at the Loscombe Crossroads. They are also conducting a feasibility study to introduce average speed cameras on the A30 between Yeovil and Sherborne. The Department for Transport acknowledges the concerns but states that decisions about road layout and safety are the responsibility of the local traffic authority (Dorset Council).

Noted (AI summary) The RCOG expresses condolences and explains their guideline development process, stating that the Shoulder Dystocia guideline will be updated to include a section on alternative maneuvers but that there is not currently enough evidence to recommend the shoulder shrug maneuver. They emphasize the importance of effective training using existing recommended maneuvers.

Noted (AI summary) NHS England acknowledges concerns about menopausal care and highlights increased awareness and demand. They describe training programmes, awareness sessions and e-learning packages that have been launched, some since Anne's death, to improve resources for healthcare practitioners. Somerset NHS Foundation Trust has developed supportive guidance for families regarding Section 17 leave from inpatient units, which is currently out for feedback and will be shared at an operational meeting for approval. They also describe planned training for mental health staff on menopause. NICE expresses condolences and states that the concerns raised are not directly attributable to NICE but are addressed to other organizations. They reference existing NICE guidance and quality standards related to suicide prevention and menopause, and indicate that the menopause guideline was recently updated and will remain under surveillance. The RCOG extends condolences and recognises the concerns raised, highlighting that management of the menopause is covered in the core training curriculum for Obstetricians and Gynaecologists, including a Special Interest Training Module and the Diploma of the Royal College of Obstetricians and Gynaecologists. Kenny & Murphy Ltd sold the incident site in March 2024 and has no influence over tenants there. However, they have discussed electrical safety with tenants at their other sites and provided them with relevant leaflets and documents.

Noted (AI summary) The Department for Transport confirms that it is not the owner of the wreck and has no legal responsibility pertaining to it, as the wreck was sold to a private individual in 1957.