2025

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Action Planned (AI summary) NHS England has shared draft guidance with systems, the Personalised Care Framework.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.

Action Planned (AI summary) NHS Greater Manchester is reviewing and amending the Standard Operating Procedure (SOP) between the Comprehensive Stroke Centre (CSC) and other Greater Manchester stroke centres to clarify specialist stroke advice. The amended wording will be formally approved by the end of February 2026.

Action Planned (AI summary) The General Medical Council (GMC) plans to launch a targeted awareness campaign in the new year, using its communication channels, to promote its existing guidance on assessing patients' fitness to drive. The GMC is also exploring opportunities for joint working with the General Optical Council. The General Optical Council will include information in its next registrant newsletter highlighting responsibilities regarding drivers' fitness to drive and explore using its annual survey to gather evidence on barriers preventing referrals. It also awaits the Government's strategy on this issue and will then work with stakeholders. The Department for Transport is considering evidence gathered during the 2023 call for evidence and findings from recent inquests, giving consideration to the process of self-declaration. The department has also developed a new Road Safety Strategy.

Action Planned (AI summary) HMP Wormwood Scrubs has reminded all managers on the IFSL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings. Practice Plus Group outlines the process they follow when a patient on the Independent Substance Free Living unit has a positive drug test result, including referral to the clinical SMS team and the Substance Misuse Non-Medical Prescriber for assessment and a clinical plan. Communication processes are in place between Forward Trust, the prison and healthcare.

Action Planned (AI summary) A multidisciplinary group has been established to advise on strengthening governance for prescribing medications following unexpected hospital admission after day case surgery, with implementation planned by May 2026. Four workstreams have been identified, and an audit is planned for September 2026.