2025

Noted (AI summary) NHS England acknowledges concerns about guidance for surgeons regarding CT scanning after abdominal surgery but notes that clinical guidelines are primarily the responsibility of NICE and Royal Colleges. They note that Clinical Quality colleagues have been asked to engage with the relevant ICB/Trust to ensure learnings have been taken. The Royal College of Surgeons of England will include an anonymised educational surgical vignette relating to the death in the Confidential Reporting System for Surgery (CORESS) surgical safety feedback reports. They will also encourage the Royal College of Surgeons of Edinburgh to do the same. The Association of Coloproctology of Great Britain and Ireland states that existing guidance on colorectal anastomotic leak management is sufficient, referring to its 2016 guidance on post-operative CRP monitoring and subsequent radiological investigation. While citing existing NICE guidance, the DHSC has shared details of the case with NICE's prioritisation team to consider if further action should be taken. The CQC has also passed details of the case to the relevant inspection team for Royal Berkshire Hospital.

Noted (AI summary) MHRA acknowledges the concerns about support belts lacking warnings and guidance, provides background on its regulatory role, and explains existing device regulations and post-market surveillance activities, including Yellow Card scheme and collaborations. It highlights manufacturer responsibilities for safety and labeling. The response includes details on the product and its instructions for use. The DHSC acknowledges the concerns regarding the lack of warnings and information on lap belt products, states that the responsibility for these concerns sits within another organisation, and will be writing to the Office of Product Safety and Standards. OPSS has written to major online marketplaces (Amazon, eBay, Temu, Shein and Alibaba) to make them aware that certain products may not be provided with suitable instructions or warnings to assure safe use by likely users, and alerted online marketplaces to its Product Safety Report published for the ORTONES belt to make clear this product should not be supplied.

Noted (AI summary) The London Ambulance Service provides a statement regarding the clinical review of the incident and details the assessment and actions taken by the paramedic at the scene, including confirming a valid DNACPR and finding no evidence of airway obstruction.

Noted (AI summary) The Minister will write to Swim England to explore how awareness of the 'Beyond Swim' accreditation scheme and associated guidance can be increased. They will also continue to work with sports bodies to ensure safety is prioritised. HSE acknowledges the concerns, explains that existing regulations (HSWA and MHSWR) apply to open water swimming events, and that relevant guidance is available from other sources. HSE will not be publishing specific guidance at this time but will raise awareness with local authority enforcement officers.

Noted (AI summary) The CQC acknowledges the concerns, noting that the care home in question is now dormant and outlining CQC's role and inspection methodology. They state that the Secretary of State for Health and Social Care is better placed to address concerns about pressures on the ED. Tameside Metropolitan Borough Council has revised its Multi Agency Concern (MAC) process to ensure providers notify families of concerns and has increased the number of quality monitoring officers to conduct more robust contract monitoring. The Department of Health and Social Care highlights the opening of an additional ward at Tameside General Hospital in November 2024 to provide additional capacity and support patient flow, as well as the £9 billion committed to the Better Care Fund to tackle delayed discharges.

Noted (AI summary) The Partnership acknowledges the concerns but cannot comment on the specific reasons for the original CDOP decision due to missing documentation. It provides assurance regarding the current child death review process, including improved data storage, family involvement, and panel operations. The Royal College of Radiologists acknowledges the concern, highlights the shortage of radiologists in the UK and the importance of written evaluations of imaging, and supports regional imaging networks to enable equitable access to expertise and resources. While willing to raise cardiac screening with England Boxing, the department is unable to provide additional funding. They highlighted existing support for Cardiac Risk in the Young through Sport England. The Royal College of Emergency Medicine acknowledges the concerns and provides context regarding the clinical management in the case. It references existing curriculum and resources related to the issues raised, but describes no specific actions taken or planned. The ICB will seek assurance of compliance with 'Shock to Survival' recommendations through Clinical Quality Review Meetings with relevant providers. It will also have access to GENOME dashboards to monitor patient safety surveillance and track progress against quality priorities. The Trust highlights several changes and quality improvements already made since the incident, including a new escalation process ('Martha's Rule'), a weekly meeting to discuss potentially harmed patients, and reviews by the CQC. All recommendations from previous Regulation 28 reports have been actioned. The Faculty of Intensive Care Medicine acknowledges the concerns, explains the role of focused echocardiography in intensive care, and highlights curriculum updates and guidelines supporting its use. They also express support for reliable provision of emergent echocardiography and image storage, but do not commit to specific actions. NHS England and the British Heart Foundation co-funded a sudden cardiac death pilot to develop mechanisms for post-mortem genetic testing, best practice pathways and engagement with patient groups. They also expect NHS Trusts to ensure protocols are appropriate in the wake of the death.

Noted (AI summary) NHS England describes the NHS Pathways triage tool and its capabilities, particularly for patients unable to move. They explain the triage hierarchy, the system's functionality since 2018, and the role of local protocols. They also mention a working group that discusses reports to prevent future deaths. South Central Ambulance Service has created a directive to staff including changes to triage processes, such as ascertaining if the patient is alone, requesting contact information, using a minimum Category 3 response for patients slipping from furniture, documenting patient position, referring cases to a clinician, and ensuring cases are not closed without an appropriate response. The directive was approved and will be issued this month.