2026

Action Taken (AI summary) • The standard ICB Nursing Needs Assessment form has been re-issued to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW). • The ICB has requested that CNTW remove the allergy section from their version of the form. • The ICB will work with CNTW to ensure that staff are aware of the correct form to use and the importance of accurate record keeping.

Action Taken (AI summary) • The Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT. • Mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust.

Action Taken (AI summary) • The Director of Nursing for the Clinical Division of Clinical & Support Services undertook a review of the patient's imaging timeline.

Action Taken (AI summary) • The Trust implemented a new electronic patient record system, Epic, in October 2025. • The system consolidates patient notes into one record for clinical and administrative data.

Action Taken (AI summary) • NWAS has implemented a number of steps to ensure more accurate estimated time of arrival information is provided to callers. • Estimated times of arrival are now provided based on information from each of the areas within the Trust: North Cumbria, South Cumbria and Lancashire, Greater Manchester, and Cheshire and Merseyside.

Action Taken (AI summary) • A single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. • Guidance to support people with understanding safeguarding and making referrals, is available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult Board websites, and links to this guidance will be further embedded within the digital referral forms. • It is clear within the joint policy and procedures that referrals should be made by telephone in the first instance, as this enables a timely and robust response to the concerns being raised.

Action Taken (AI summary) • The organisation has thoroughly investigated the concerns and reflected seriously upon the contents of the report, the evidence heard, and the findings made at the inquest. • Investigations and remedial actions commenced earlier following the identification of concerns and actions to be taken, as part of agreed lessons learned outcomes, with the approval of the Tameside Safeguarding Team in August and September 2025. • The following actions have been incorporated and discussed across the wider organisation as part of our approach to continuous quality improvement and lessons learned following a full audit of the service by the senior management team and a thorough investigation.