2025

Noted (AI summary) The York & Scarborough Teaching Hospitals NHS Foundation Trust acknowledge that timely referral of patients to a transplant centre is important and have circulated this message to relevant clinicians. They state that Mr Morrell was undergoing optimisation of therapy, hence urgent referral for transplant assessment would not have materially advanced his management.

Noted (AI summary) NHS England acknowledges concerns around the transfer of mental health patients back to primary care and highlights the Personalised Care Framework (PCF) which sets out core aspects of care and emphasizes the responsibility of services to support safe transitions. It also describes existing procedures for care planning meetings and information sharing during discharge. The Department for Health and Social Care acknowledges the concerns and states that NHS England has developed draft guidance, the Personalised Care Framework (PCF), to support local systems in improving the continuity of care for people with mental health needs. It emphasizes the responsibilities of services to support safe transitions between secondary and primary care.

Noted (AI summary) South Central Ambulance Service acknowledges concerns about handover delays but states the issue originates with hospital trusts and asks that future reports be directed to the appropriate organisation. It also describes NHS England initiatives and commissioned targets for handover times.

Noted (AI summary) Optum conducted an internal review of the EMIS Web system and concluded that no software developments beyond the existing functionality are required to mitigate the risk raised in the report, explaining how the system manages repeat prescriptions and their expiration.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns raised but states that NHS England will provide a full response, as the concerns are more appropriately addressed by them.

Noted (AI summary) Suffolk County Council acknowledges the report but clarifies that the responsibility for adult mental health provision rests with NHS commissioners and providers. It states its role is concerned with statutory functions under the Care Act, including safeguarding and social care assessment. Suffolk Constabulary is committed to improving awareness and training for frontline staff in relation to adult mental health. Planned actions include vulnerability training scheduled for Autumn/Winter 2026 and participation in a multi-agency audit of NHS 111 Option 2.

Noted (AI summary) The BSG acknowledges the concerns regarding colonoscopies for patients over 80, stating that decisions should be individualised, balancing risks and benefits.

Noted (AI summary) NHS England is working with the Resuscitation Council UK (RSUK) to design an updated Neonatal Life Support (NLS) course including homebirth scenarios, and funding is provided for practitioners to have this training. They will work with the UK Midwifery Study System (UKMIDSS) to improve national data collection. NICE will review existing guidance to consider the feasibility of defining 'high' and 'low' risk pregnancies, and clarify differentiation between risks of pregnancy and labour. They reference existing NICE guidelines covering intrapartum care and midwifery staffing. The RCOG expresses condolences and defers to other organisations (RCM/NMC and NHSE/DHSC) to address the specific concerns raised regarding national guidance, training, data collection and staffing models for home births, while referencing existing NICE guidance. The RCM states it will advocate for national guidance on when transfer to hospital is necessary, promote existing guidance and resources, and will continue to advocate for sustained investment in maternity staffing to support safe services. The Nursing and Midwifery Council (NMC) will strengthen midwifery standards, specifically mapping proficiencies against previous maternity reviews. They propose to feed into a task force addressing bespoke training needs analysis for midwives in home birth teams. The Department of Health and Social Care acknowledges the need for urgent action to improve homebirth services and will work with NHS England to address the coroner's concerns. This includes funding a new neonatal resuscitation training programme with homebirth scenarios. The JRCALC guidelines have been amended to clarify that if bleeding persists despite a firm uterus after birth, other causes such as trauma should be reconsidered. The guidance also specifies continuous observations form part of ongoing management.

Noted (AI summary) OPSS highlights industry led labelling initiatives to address risks. Officials will communicate the new industry labelling initiative to relevant groups to raise awareness. The Department highlights the Online Safety Act (OSA) which requires companies to prevent users from encountering illegal content and remove such content swiftly. Ofcom can issue information notices at the coroner's request, requiring services to provide data and Data Preservation Notices to preserve a child's data. BAMA has developed a new caution mark and statement that can be used to provide additional detail on the potential problems which can arise if the aerosol dispenser is not used in accordance with the manufacturer’s instructions. The caution mark will be placed in the top two-thirds of the back of the pack copy to ensure that it is noticed by the consumer. The Department for Culture, Media and Sport acknowledges the report and confirms that the Department for Science, Innovation and Technology (DSIT) leads on online safety.