2025

Action Planned (AI summary) Royal Cornwall Hospital is changing their language in the Emergency Department when asking parents about how babies are fed from ‘bottle’ to ‘formula’ and this will be reflected in ED documentation. Maternity services use routine enquiry about the exact nature of bottle feeding as a mandatory question at every safe opportunity and have an Enhanced Continuity Pathway developed and implemented along with pregnancy circles with face-to-face translators. Cornwall Council has secured funding to rewrite/update the ‘Essential Guide to feeding and caring for your baby’, deliver a mandatory webinar on language/terminology and safe formula guidance by the end of January 2026, finalise and publish Interpretation SOP and add targeted checks on recording "what’s in the bottle". Cornwall Partnership NHS Foundation Trust has instructed Minor Injuries Unit staff to ask for specific details if there are any concerns about a child’s nutrition including what is being fed. Staff have also been reminded that children attending the MIU should be weighed on each visit, and for those aged 2 and under, this should also be recorded in the child’s red book.

Action Planned (AI summary) Conwy County Borough Council has agreed with the property owner to replace the railings to the right of the Waterloo Hill junction with a more suitable boundary treatment by March 31st, 2026. They have also conducted a route speed limit review for the A548 and propose to reduce the speed limit to 40mph, shortly to be advertised as a Traffic Regulation Order and proposing changes and improvements to traffic warning signs to be completed by March 31st 2026.

Action Planned (AI summary) HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.

Action Planned (AI summary) Barts Health NHS Trust's Haemoglobinopathy Coordinating Centre (HCC) is developing a website with information to support families and has appointed a governance lead to lead on network wide quality improvement and governance. They are also involved in an exhibition to challenge staff attitudes and behaviours towards patients. Maylands Healthcare has undertaken an annual audit of patients with Sickle Cell Disease, proactively contacts them for medication reviews, liaises with specialists, changes medications to electronic repeat dispensing, and shares learning points from Significant Event Analyses with staff. They have also added clear alerts in each clinical record and all clinical staff have undertaken mandatory Sepsis training. The Department of Health and Social Care has introduced an incentive for GPs to identify patients who would benefit most from continuity of care, and has implemented "Jess's Rule", encouraging clinicians to re-evaluate symptoms if a patient's condition remains unresolved after three consultations. NHS England is also working to improve education and awareness of sickle cell disease amongst healthcare staff and for patients and carers. Partnership of East London Co-operatives (PELC) has shared organisational learning regarding the importance of reviewing patient records and included this requirement in staff contracts. They are also implementing an alert within clinical records for all children presenting with sickle cell disease.

Action Planned (AI summary) NHS England acknowledges concerns about A&E capacity, bed availability, and specialist care for elderly patients with dementia. The trust is actively developing a dedicated frailty area within their Same Day Emergency Care unit and focusing on using frailty scores to guide patient placement and prioritisation. The Department of Health and Social Care acknowledges concerns about A&E waiting times, bed availability, and specialist care for the elderly, noting that NHS England will respond in full. They highlight the Urgent and Emergency Care Plan for 2025/26, which includes investments and actions to improve performance.

Action Planned (AI summary) NHS South Yorkshire ICB convenes an Opioid Safety Group and will review and recirculate guidance for practices on recording drug-seeking behavior. They will share the report and response at multiple forums.

Action Planned (AI summary) The Trust is revising its Rapid Response Standard Operating Procedure to ensure senior clinical oversight of referrals, revising its CAMS policy, considering a dedicated CAMS workforce, and promoting the use of the Urgent Mental Health Helpline.

Action Planned (AI summary) HMPPS is reviewing national prison officer training, developing interim upskilling sessions on recognising risks and triggers, and considering upgrading Victorian-style windows to anti-ligature designs. They are concluding a project to convert 50 cells across 13 locations to a fully ligature‑resistant standard. HCRG is retraining reception nurses, introducing an Early Days in Custody (EDiC) Nurse role, improving identification and escalation of urgent mental health referrals, and reviewing the Mental Health Operational Standard Operating Procedures and referral processes.

Action Planned (AI summary) Mid and South Essex NHS Foundation Trust has updated relevant policies and flowcharts to assist staff with managing patients at high risk of self-harm. The Trust's Mental Health Lead and Prevent Lead Nurse is undertaking a program to raise awareness of this updated staff guidance and has added content to existing training. Essex Partnership University NHS Foundation Trust states that its Mental Health Liaison Team includes nurses, health care assistants, psychologists and occupational therapists and that patients can be reviewed by a consultant if needed. The Trust is currently reviewing its Standard Operating Procedure (SOP) in order to cover the above provisions, which will be completed by May 2026.

Action Planned (AI summary) GMP is undertaking a review of policies, delivering updated training to call handlers, reinforcing escalation protocols, and implementing quality assurance measures through supervisory reviews. The FCCO's in-house guidance system, Sherlock, will be updated and new training will incorporate these revisions.

Action Planned (AI summary) Sandwell Council is proposing a road safety and public realm improvement scheme for B4517 Owen Street, Tipton, including new pedestrian crossings and traffic calming. It is also proposed to extend the principles of this scheme to include B4517 High Street, including enhanced lighting and a new 20mph zone.

Action Planned (AI summary) The Trust has established a new Nutrition and Hydration Safety Steering Group, revised malnutrition and hydration policies, and is launching a new e-learning package for staff. A formal process will be agreed to ensure improved oversight of Harm Free Care audit results and a ward league table will be produced monthly by the Quality Team.

Action Planned (AI summary) The Trust is undertaking a quality improvement program to improve processes for learning from deaths and will allow sharing of learning between teams and across hospital sites. The Rheumatology team will invite Cardiology colleagues to their meetings and present Miss Muir’s case at the Essex Rheumatology meeting to raise awareness.