2025

Noted (AI summary) EMAS is actively working with local mental health crisis teams to formalise referral pathways and will undertake an After Action Review on 8 January 2026 with all parties involved in the incident. Mental Health Awareness training is also under review for January 2026. The Trust provided bespoke training on the Mental Capacity Act for the Clinical Access Line and Crisis Resolution Home Treatment team. They also developed flow charts to support staff in considering mental capacity and shared these with staff, displaying them in team offices. The RCGP provides context on its role in setting standards and supporting GPs and highlights existing training resources. It suggests system pressures impact GP decision-making and there is an opportunity to address the system aspects of referral processes.

Noted (AI summary) The Trust is implementing dynamic strategic conveyance, directing patients to hospitals outside their usual catchment area. They are also working to implement the 45-minute handover protocol and initiate 'rapid handover' requests during periods of high demand. SCAS investigated the incident, finding one call non-compliant due to documentation errors, and shared learning with the call handler. It details actions taken when a 999 call is received and summarises the call cycle and audit outcomes. The Department acknowledges the concerns and outlines the government's commitment to improving urgent and emergency care. It highlights key actions from the Urgent and Emergency Care Plan and improvements in ambulance response times and handover delays, while noting SCAS has responded in full to the concerns. The hospital has been working through an UEC improvement programme since January 2025, including implementation of the national 45-minute maximum ambulance handover time standard, Frailty SDEC and Trusted Assessor introductions, and NerveCentre pre-arrivals screen. They have increased ambulance handover space and medical pathway by introducing RAU and AAU.

Noted (AI summary) The team reviewed the MNSI report, process, and findings and concluded that their investigation process was correctly followed. A note has been added to their investigation record to highlight the findings of the inquest. The RCOG highlights the Scientific Impact Paper (SIP) number 73, second edition, which addresses impacted fetal head at caesarean birth and sets out detailed descriptions of safe technique. The ABC (Avoiding Brain Injury in Childbirth) programme incorporates these techniques and will be rolled out to maternity units in England as part of a national programme by NHSE.

Noted (AI summary) The Department of Transport notes that there are no specific statutory guidance or mandatory distance regulations for yellow lines near junctions. The decision rests with the local authority, and traffic signing is devolved to the Welsh Government. The Minister explains police driver training standards, noting that decisions on crewing are operational matters for Chief Constables. Pursuits resulting in a fatality are referred to the Independent Office for Police Conduct. South Wales Police acknowledges the concerns about crewing of Road Policing Unit officers during pursuits, but states its training and operational model are designed to ensure public safety and officer competence. They highlight national standards, training, and post-pursuit review processes, while also emphasizing the need to balance operational effectiveness and resource availability, deeming single crewing the most practical option.

Noted (AI summary) NHS England states that the concerns will be dealt with by SATH and there is no action for NHS England to take as the issues fall outside of their role. The response provides general information about the Frontline Digitisation Programme and EPR systems, and notes that NHS England will review SATH's response. The hospital trust is raising Ms. Silcock's case as a Patient Safety Investigation (PSII) and will develop a single referral email for each speciality for referral for outpatient follow-up within the next 3 months. A project feasibility request has also been raised to assess the need for a digital solution to support referral management.

Noted (AI summary) NHS England refers to updated guidance regarding risk of harm to self, and states that secure access to fire escapes should be embedded within providers’ risk assessments. They state that they cannot comment further on the specific local risk assessment and direct the Coroner to the Birmingham and Solihull Integrated Care Service. The trust has updated the Environmental Risk Assessment to include the Fire Escape, installing metal fence panels and an eight-foot-high gate on the ground floor, as well as metal panels at the top of the fire escape platform. The ICB will share learning from this incident with all local mental health and rehabilitation providers by 17th December 2025. CQC acknowledges the concerns and notes that the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 apply to registered providers. They signpost to information regarding fire safety and environmental safety on their website but state they are not aware of specific guidelines regarding fire escapes in rehabilitation settings.

Noted (AI summary) The Department of Health and Social Care references NICE guidance on epilepsy, the Epilepsy Self-Management Programme, and the Clive Treacey Checklist regarding SUDEP risk assessment. They note that medical schools and royal colleges set their own curricula and that doctors are responsible for keeping their clinical knowledge up to date.

Noted (AI summary) Response from Deputy CEO and Chief Medical Officer, University Hospitals Birmingham NHS Foundation Trust, with no specific actions mentioned.