2025

Action Planned (AI summary) The Department is exploring ways to improve the safety and welfare of children in martial arts, asking Sport England to work with the Martial Arts Safeguarding Group, and ensuring parents understand the difference between regulated and unregulated competitions.

Action Planned (AI summary) NHS England highlights existing funding for thrombectomy services and ongoing support for UHSx; it mentions regional access to 24/7 services and internal discussions regarding PFD reports to share learning. The Trust has extended access to Mechanical Thrombectomy for Sussex patients through mutual aid pathways with UCL and Southampton, approved a business case to extend the local service to 7 days a week, 12 hours a day, and is actively recruiting staff, aiming for 24/7 service; it is installing a second bi-planar, expected to be operational by September 2025.

Action Planned (AI summary) NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.

Action Planned (AI summary) NHS England will ensure emphasis on escalation of deteriorating patients with skin and soft-tissue infections during a revisit of statutory and mandatory training for infection and prevention control this year. The Trust is implementing an Electronic Prescribing and Medicines Administration (EPMA) system across both sites, which will provide a record of medication activity. In the interim, a Patient Safety Learning Alert has been developed, requiring staff to document reasons for drug omissions.

Action Planned (AI summary) NHS Greater Manchester has begun a locality practice review in Oldham, reminded staff of their responsibilities via a Take 5 Briefing, reminded staff about Hospital Passports, and are monitoring compliance with the Oliver McGowan mandatory training. The Trust has reviewed and strengthened Learning Disability and EPO policies, enhanced staff training on the Mental Capacity Act, increased visibility and utilisation of Hospital Passports, and improved communication with care providers. Mr Fernandez’s death was referred to LeDeR the day following his death. Oldham Council's Adult Social Care will implement an action plan to address concerns raised in the report, with a target timeframe of June this year, and confirms its IMCA service can cover medical best interest decisions. Oldham Council ASC plans to create a 7-minute briefing and a risk rating framework for medical best interest decisions, add documents to the ASC SharePoint site, and include learning in MCA theory to practice training, with a target commencement date of June 25.

Action Planned (AI summary) The Trust conducted a system-based investigation into the death, identifying weaknesses in change of address and medication compliance management. Actions include a written reminder to clinical staff about recording address changes in Rio, and a review of the standard operating procedure for non-contact with appointments to ensure consistent escalation to the MDT. Birmingham City Council, having had no prior involvement with the deceased, will add guidance clarifying the use of Section 2 versus Section 3 of the Mental Health Act to Birmingham and Solihull Mental Health Foundation Trust's Mental Health Policy. The Council details its information-sharing practices with landlords, noting that the extent of information provided depends on how the resident accesses accommodation.

Action Planned (AI summary) The government acknowledges concerns around emergency service pressures and is working with NHS England to address them, with a focus on ambulance response times and handover delays; the upcoming 10-Year Health Plan will set out radical reforms for the NHS and address these issues.

Action Planned (AI summary) Police officers are being trained to dial 999 from the scene for medical support, and SWAST has implemented a new communication pathway to improve inter-agency information sharing. SWAST is implementing a Timely Handover Process at RCHT to instigate rapid handover if not undertaken within 90 minutes of arrival. Devon & Cornwall Police is participating in a multi-agency group to promote closer working arrangements between emergency services, with meetings scheduled to identify and address specific areas for improvement. The Assistant Chief Constable has reiterated the expectation that sergeants can redeploy police resources in liaison with an inspector and/or the Force Incident Manager.