2025

Noted (AI summary) NHS Birmingham and Solihull acknowledges the concerns raised and will work with Black Country ICB to coordinate a single response. The ICB takes the recommendations seriously and is committed to support Black Country ICB and WMAS in delivering necessary improvements. West Midlands Ambulance Service has implemented several actions, including face-to-face mandatory refresher training for breech birth in 2026-2027, resumption of the e-PROMPT course, a Trust focus on learning and improvement of obstetric emergencies, and removal of out-of-date WMAS Maternity Action Cards from all Trust Vehicles. They have also issued a clinical notice to all staff to remove and destroy the out-of-date cards. AACE acknowledges the concerns and explains its role in providing advisory guidelines (JRCALC) for ambulance services. While AACE is not responsible for training, it has shared the report with relevant networks for consideration, noting variations in paramedic training for maternity care and breech birth.

Noted (AI summary) Cheshire Constabulary provides background information on the Right Care, Right Person policy and explains their actions in this specific case, noting that hospital staff made further enquiries and determined they no longer required police assistance.

Noted (AI summary) The Trust acknowledges the concerns raised in the PFD report regarding the death of Mr. Horton, but states that a falls risk assessment was completed and wound care was delivered in accordance with Trust policy. The Trust maintains a skin integrity improvement plan and a discharge action group is in place.

Noted (AI summary) Derbyshire County Council is exploring the feasibility of removing an access bridge to reduce flood risk and constructing a Flood Alleviation Scheme on the Spital Brook. They will also continue to work collaboratively with the Environment Agency to encourage residents to sign up for flood warnings and review existing flood plans and evacuation procedures. The Environment Agency expresses condolences and explains that while they have powers to build flood defences, they are not able to eliminate the risk of flooding entirely. They will continue to work with communities and provide a Flood Warning Service and carry out winter maintenance walkovers. Defra acknowledges the concerns and highlights its national responsibility for flood risk management. The Minister will meet with representatives from Derbyshire County Council and the Environment Agency to discuss flood protection in Chesterfield ahead of winter.

Noted (AI summary) The Home Office acknowledges the concerns and outlines government funding provided to West Midlands Police. Decisions around resourcing are the responsibility of the Police and Crime Commissioner and Chief Constable.

Noted (AI summary) The Road Policing Unit provides context from the perspective of detectives and Traffic Management Officers, stating that the speed limit does not need to be reduced and offering to speak to the Coroner or the family to explain their views further; the decision of the road's safety sits with HCC colleagues. Hertfordshire County Council will maintain the current speed limit, apply targeted vegetation clearance, consider area-wide rural speed management approaches as part of their Speed Management Strategy review, and strengthen messaging to the public on road safety and vegetation responsibilities. They will also propose regular multi-agency collision review meetings.

Noted (AI summary) The Care Quality Commission explains its role and inspection methodology and states that it is outside CQC's scope to amend regulations to allow HCAs to take on medical or nursing observations, noting that the report has also been sent to The Secretary of State for Health and Social Care. The Department of Health and Social Care will ask NICE to consider developing a national standard on the prevention and management of choking hazards in domiciliary and residential care settings, after concerns were raised about a lack of basic observation ability of carers.