2025

Noted (AI summary) The DHSC acknowledges concerns about guidance on self-neglect and hoarding disorder, pointing to existing NICE guidance and recent court judgements. They will continue to disseminate such guidance and caselaw through its partners and networks.

Noted (AI summary) NHS England acknowledges concerns about the use of NHS Pathways to triage mental health situations, notes it has already considered management of callers at risk of suicide, and will keep the clinical content under review. It also notes that the triage system elicited the correct information triggering the approved ambulance response.

Noted (AI summary) The BSG will work with Guts UK to develop a patient information leaflet for hiatus hernia, highlighting the need for extra vigilance following diagnosis of a para-oesophageal hernia. The DHSC acknowledges the concerns and explains that NHS England is responsible for providing information on NHS.UK, which is not designed for specialist clinical education or to raise awareness of conditions among the medical community, and CPD is the responsibility of the individual doctor.

Noted (AI summary) NHS England discusses reports to prevent future deaths in a working group and escalates risks nationally through committees, referencing the Three year delivery plan for maternity and neonatal services and the Maternity and Neonatal Safety Improvement Programme. NHS Lancashire and South Cumbria ICB outlines measures in place to monitor compliance, including the reporting and escalation process and also that the North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The Trust has reviewed practices, policies, and procedures, implemented mandatory training on candour, revised investigation processes, increased bereavement support, and implemented measures for consultant oversight. They also have enhanced incident review and executive oversight processes, including learning response leads. NHS Lancashire and South Cumbria ICB clarifies the independence and current availability of its Maternity and Neonatal Independent Senior Advocate role, noting it's under national evaluation and currently unable to accept new referrals.

Noted (AI summary) NHS England acknowledges concerns, points to ICB responsibility for local care provision, highlights national guidance, and explains the purpose of the Special Allocation Scheme. NHS Devon highlights improvements to the Special Allocation Scheme including reviewing the process the practice has followed, and a modification to the SOP requiring written confirmation from Practices that they considered all possible alternative approaches prior to placement, enacted in May 2025. Devon Partnership Trust highlights the planned opening of The Brook, a ten-bedded inpatient unit for adults with learning disabilities and/or autism, and the commissioning of a Learning Disability/Autism Outreach team, both expected in summer 2025.

Noted (AI summary) NHS England notes the local Trust has completed immediate deployment of RCEM guidelines for procedural sedation in the ED and is reviewing the safe sedation policy; weekly discharge planning meetings are held, and informatics is reviewing discharge letters. The DHSC points to existing 'Hospital discharge and community support guidance' and states that NHS England will ensure the guidance is followed, with officials working to prevent similar situations in the future.

Noted (AI summary) The DHSC acknowledges concerns about online prescribing and information sharing, highlighting existing guidance and the role of the GPhC, and referencing the cross-sector Suicide Prevention Strategy for England.

Noted (AI summary) The RCOG acknowledges the coroner's concerns regarding the lack of guidance on managing abnormal antenatal CTGs, emphasizes the need for individualised care plans and refers to NHS England guidance on computerised CTG use. NICE acknowledges the coroner's concerns and will consider reviewing the evidence on antenatal CTG interpretation and actions, and will work with others to see if they can produce a practice guide to inform practitioners.

Noted (AI summary) RCEM acknowledges the concerns raised, referencing its guidance on staffing levels and track/trigger tools for children and adults in ED, noting that the national PEWS was designed for inpatient use and an ED version is being developed and tested. RCPCH notes that blood pressure is now included in the national PEWS. They are currently in the process of audit, review and revision and update of their current standards, to be published later in 2025. The Trust has updated its guideline so that all paediatric patients with persistent abnormal vital signs at the point of discharge, must be referred to Paediatrics prior to discharge and has consultants cover in place consistently from 09:00 to 23:00 (Monday to Friday).

Noted (AI summary) The Department for Transport acknowledges the coroner's concerns, highlights the falling number of fatalities for young drivers, and mentions the THINK! campaign and development of a new road safety strategy without committing to specific changes related to the concerns raised.