2026

Action Taken (AI summary) • The Force has reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation. • Changes have been made to how that information is recorded and shared with those engaged in enquiries to locate the missing person and to ensure that all information is readily available to those conducting reviews of risk assessments. • The Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments.

Action Taken (AI summary) • The matter has been discussed with the staff member involved to ensure that there is clear understanding of expectations in the future. • The Trust has taken steps to further strengthen the relevant section of the Clinical Supervision Policy. • A Trust- wide Policy Alert, via email on 27th April

Action Taken (AI summary) • The RCGP agreed that clinical correspondence, including reports from NHS 111, must be reviewed by a clinician before any decision is made about further action. • The RCGP's curriculum reflects the responsibility of GPs to respond to clinical correspondence in a timely manner to maintain safe patient pathways. • The RCGP supports CQC guidance that where non-clinical staff are involved in workflow tasks, there must be appropriate safeguards, supervision, training, and audit in place. • The GP practice has revised its workflow so that all clinical documents received from providers, including NHS 111 and out-of-hours services, are now reviewed by a clinician rather than administrative staff. • All incoming 111 and out-of-hours documents are attached to the patient record and sent as a clear task directly to a clinician as part of their daily workflow. • The GP practice now ensures that all consultation notes and reports are added to the patient’s medical record, coded and free-texted by the clinician.

Action Taken (AI summary) • The echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results, operational since 2019. • The pathway includes criteria based on best practice and guidelines from the British Society for Echocardiography. • The pathway is shared with the cardiac physiologist team and discussed in team meetings and reviewed annually.

Action Taken (AI summary) • An updated standard operating procedure has been implemented requiring MDT scheduling to take account of named nurse availability. • Where attendance of an individual’s named nurse is not possible, an appropriate alternative clinician is required to physically attend in their place, preparing with the patient beforehand. • Attendance at MDTs by a patient’s named nurse, or an alternative, is formally recorded, with ongoing compliance monitored through routine monthly audits by a senior practitioner.

Action Taken (AI summary) • The Trust implemented a new electronic patient record system in October 2025. • This system allows internal users to send secure messages to each other on patient records, creating a new line of communication internally. • This has reduced the pressure for response from the medical team for the Medical Assessment Unit by providing an alternative means of communication for internal users.

Action Taken (AI summary) • The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations. • Next of kin and emergency contact details are now mandatory fields and are completed at triage where the information is available. • The Trust has undertaken a programme of Trust‑wide engagement events to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’.

Action Taken (AI summary) • Officers from the council’s health and safety team attended the location to inspect the breach in the stone wall. • A site-specific risk assessment for the site had been previously undertaken by council officers for this area and this followed national guidance and methodology; this previous assessment was reviewed and updated to reflect the findings from the inquest. • The council will install a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below.

Action Taken (AI summary) • A revised escalation and referral protocol has been implemented within the Cardiac Device Clinic. • A mandatory referral trigger is now in place if a device has lost a twofold safety margin, documented in the "Managing the Unwell Patient Standard Operating Procedure". • The Standard Operating Procedure has been shared with all Physiologists and will be presented at the departmental Quality and Safety meeting on the 13th of May.