2025

Action Planned (AI summary) The government launched a Road Safety Strategy including a consultation on mandating vehicle safety technologies covered by UN R158. The UK will raise the possibility of including goods vehicle trailers in the scope of UN R158 at the next UNECE working group meeting.

Action Planned (AI summary) YAS will send a clinical alert reinforcing that known high-impact risks, such as swallowing or choking risk, should be explicitly raised at handover where they are clinically active or present a foreseeable risk of harm. Learning from this case will be shared through clinical forums and with system partners. The hospital implemented an immediate action ensuring patients in the Emergency Department are not given food without the oversight of a registered nurse. The Trust has a Standard Operating Procedure (SOP) for Sip Testing in place along with training.

Action Planned (AI summary) • The Trust is developing a new private care protocol to guide clinicians on how to approach circumstances when a patient is accessing care from a private healthcare provider. • The protocol will operate within the existing policy framework, linked to existing policies and procedures for information sharing and record keeping. • Work to develop this new protocol is underway and will be completed by the end of this month, applying to new and existing patients.

Action Planned (AI summary) • The approach to monitoring service users following changes to antipsychotic medication has been strengthened and is being implemented, with full standardisation across all relevant services to be completed by 1 March 2026. • Any request for enhanced monitoring following medication changes is now formally logged and reviewed at the first daily multidisciplinary planning meeting. • The process includes a structured clinical discussion to confirm the level of risk and the intensity of monitoring required, clear allocation of responsibility to a named clinician, and formal recording within the clinical diary system.

Action Planned (AI summary) The ENA has convened member companies to improve arrangements following the death. They plan to produce industry guidance on health and safety risk assessments for low-hanging overhead lines and promote innovative monitoring technologies by September 2026.

Action Planned (AI summary) NICE acknowledges the difficulty of recognising sepsis in children and highlights existing guidance and screening tools. They are planning to update their guidance on paediatric sepsis in 2026, considering adapting the current 'traffic light' system to one based on NPEWS.

Action Planned (AI summary) Royal Cornwall Hospital is changing their language in the Emergency Department when asking parents about how babies are fed from ‘bottle’ to ‘formula’ and this will be reflected in ED documentation. Maternity services use routine enquiry about the exact nature of bottle feeding as a mandatory question at every safe opportunity and have an Enhanced Continuity Pathway developed and implemented along with pregnancy circles with face-to-face translators. Cornwall Council has secured funding to rewrite/update the ‘Essential Guide to feeding and caring for your baby’, deliver a mandatory webinar on language/terminology and safe formula guidance by the end of January 2026, finalise and publish Interpretation SOP and add targeted checks on recording "what’s in the bottle". Cornwall Partnership NHS Foundation Trust has instructed Minor Injuries Unit staff to ask for specific details if there are any concerns about a child’s nutrition including what is being fed. Staff have also been reminded that children attending the MIU should be weighed on each visit, and for those aged 2 and under, this should also be recorded in the child’s red book.

Action Planned (AI summary) HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.

Action Planned (AI summary) Barts Health NHS Trust's Haemoglobinopathy Coordinating Centre (HCC) is developing a website with information to support families and has appointed a governance lead to lead on network wide quality improvement and governance. They are also involved in an exhibition to challenge staff attitudes and behaviours towards patients. Maylands Healthcare has undertaken an annual audit of patients with Sickle Cell Disease, proactively contacts them for medication reviews, liaises with specialists, changes medications to electronic repeat dispensing, and shares learning points from Significant Event Analyses with staff. They have also added clear alerts in each clinical record and all clinical staff have undertaken mandatory Sepsis training. The Department of Health and Social Care has introduced an incentive for GPs to identify patients who would benefit most from continuity of care, and has implemented "Jess's Rule", encouraging clinicians to re-evaluate symptoms if a patient's condition remains unresolved after three consultations. NHS England is also working to improve education and awareness of sickle cell disease amongst healthcare staff and for patients and carers. Partnership of East London Co-operatives (PELC) has shared organisational learning regarding the importance of reviewing patient records and included this requirement in staff contracts. They are also implementing an alert within clinical records for all children presenting with sickle cell disease.