2025

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) 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. 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. 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.