2025

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) 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) 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.

Action Planned (AI summary) The Royal College of Pathologists will raise the issue of including IgE testing and cross-referencing other autopsy guidelines with the author group of the relevant autopsy guideline. Cambridgeshire Constabulary has established liaison with Scenes of Crime Officers, amended and re-issued internal procedural guidance, incorporated updated guidance into the 'SaferTogether' newsletter, and included revised processes in ongoing training cycles for child death investigations.

Action Planned (AI summary) The Department for Transport will highlight the particulars of the case at the relevant UNECE forum in May and collaborate on whether specific provisions are necessary for R13H; officials will also gather relevant information to understand potential risks to existing vehicles and consider retrospective action. Toyota has been gradually implementing changes in the design of its new cars to ensure that drivers are provided with more information about any reduction in tyre air pressure and are discouraged from driving when tyres are in a dangerous condition, and regularly communicates through its social media, customer communications and website channels to promote safe driving.

Action Planned (AI summary) NHS England has shared draft guidance with systems, the Personalised Care Framework. North Staffordshire Combined Healthcare NHS Trust has implemented a process to contact patients awaiting Standard Assessment Framework assessments, requires key workers to have confirmed appointment dates before allocation, and clarified transition timescales. North Staffordshire Combined Healthcare NHS Trust is implementing a mandatory electronic alert system for Community Psychiatric Nurses when a service user is newly allocated or has not received an appointment within a specified timeframe, and is also transitioning to co-produced care planning and move away from Care Programme Approach (CPA).

Action Planned (AI summary) NHS England's Regional Chief Nurse is overseeing a system-wide review with the provider trust, looking at medication safety incidents and clinical incidents. The Patient Safety Group has strengthened leadership challenge and is monitoring medicines safety and deterioration. The Princess Alexandra Hospital is reviewing this incident under its governance processes and considering additional measures, including enhanced training and monitoring. The Mandatory Learning Oversight Group is actively reviewing the training framework, including whether medicines management training should move from essential to mandatory status.