2025

Action Planned (AI summary) The DHSC acknowledges the coroner's findings and states that NHS England is expanding elective care reform initiatives and introducing digital innovations to reduce patient wait times and improve diagnostic turnaround. They are also investing in workforce expansion and streamlining referral pathways.

Action Planned (AI summary) NHS Devon will cascade additional funding to Devon Partnership NHS Trust to support the implementation of more Clozapine clinics to increase capacity. NHS Devon will ensure that outcomes of discussions with the Royal College of Psychiatrists regarding new national evidence are shared and implemented within local systems and guided by national clinical standards. The MHRA acknowledges the concerns and is currently reviewing the product information for clozapine, intending to engage with stakeholders to improve clarity for healthcare professionals and patients, with completion expected this year. Devon Partnership NHS Trust has set up Clozapine clinics where staff discuss side effects with patients, including additional questions about physical health, palpitations, chest pain, breathlessness, and dizziness. The Trust is using a new Electronic Patient Records system (SystmOne) and working to improve communication between those involved in patient care. The practice withdrew from the DPT phlebotomy agreement due to patient safety concerns and highlighted clozapine monitoring at the LMC. They also educated GPs on clozapine side effects and plan to add an alert to medical records, with an audit of clozapine patients planned.

Action Planned (AI summary) The Trust will update its Fluid Balance policy, roll out a new fluid balance chart with colour coding and other improvements, introduce mandatory afternoon checks, and update its Record Keeping Audit methodology to maintain direct oversight of fluid balance chart completion.

Action Planned (AI summary) HMPPS has finalised Barricade Guidance, which will be issued to all approved premises staff on 1st August 2025, with staff required to acknowledge receipt by the end of September 2025. A new digital referral process is in place to pull information from prison and probation systems, and Oasys is used by Probation Practitioners to assess risk.

Action Planned (AI summary) The Ministry is working to deliver the Renters (Reform) Bill which will abolish section 21 evictions, is increasing funding for homelessness services and is chairing an Inter-Ministerial Group focused on developing a long-term strategy to get back on track to ending homelessness. It is also delivering 1.5 million new homes and administering the Local Authority Housing Fund.

Action Planned (AI summary) Unite Students is reviewing procedures for dealing with calls made to the ECC to effectively triage calls received and ensure appropriate questions are asked to understand the seriousness of enquiries. Welfare checks now escalate to the emergency services immediately if staff can't enter a room, and staff are trained in mental health awareness.

Action Planned (AI summary) National Highways will repair the boundary fence at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure. They are also in discussion to establish if it is feasible to maintain a more remote access to the electrical cabinets and remove the ladder from the retaining wall.

Action Planned (AI summary) Pending IT integration, the surgery will implement temporary measures recommended by the ICB, alongside other Surrey practices, and continue timely verbal and email communication with GPiMHS when concerns arise. The practice has already contacted the ICB and raised awareness with staff. By mid-April, Surrey Care Record will implement a live feed from the GP system to show the entire consultation free text, including historic consultations, to health professionals treating the patient.

Action Planned (AI summary) NHS England has committed to issue a reminder to clinicians in NHS trusts on the importance of assessing for, and making, reasonable adjustments when supporting autistic people to gain access to health services and there is liaison ongoing with Disability Stockport in relation to a future Masterclass.

Action Planned (AI summary) West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.