2026

Action Taken (AI summary) • NHS England stated that established guidance already supports safe and standardised practice for the insertion and management of intravenous (IV) access devices. • The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. • National infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National guidance.

Action Taken (AI summary) • The metal access ramp has been completely removed. • The entrance has been restructured to eliminate the previous ramp arrangement and replaced with a small, stable step. • Additional fixed grab rails have been installed on both sides of the entrance.

Action Taken (AI summary) • Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework.

Action Taken (AI summary) • The location on the A1068 Sheepwash Road has been identified and recorded by the Council’s Highways service as a high-risk site for the purposes of traffic safety assessment. • The site has already been subject to resurfacing and road marking works during 2025/26 and has also been included within the 2026–2027 Local Transport Plan programme for traffic safety improvements. • The Council has now commenced a review of the site to consider options to improve the visibility and awareness of the bend for road users, including the potential use of advance warning measures.

Action Taken (AI summary) • Departmental officials made enquiries with NHS England to address the coroner's concerns. • The Department of Health and Social Care is taking action to address the misuse of the title 'nurse' by unregulated individuals.

Action Taken (AI summary) • NHS England implemented new ambulance standards across the country in 2017. • NHS Ambulance Services are required to process 999 calls through an approved triage system. • The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).

Action Taken (AI summary) • Officials made enquiries with NHS England to address the coroner's concerns. • The government is committed to improving care for people with neurological conditions, including epilepsy, and ensuring they receive the support they need.

Action Taken (AI summary) • An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be discussed at the Learning Group where potential themes are discussed.

Action Taken (AI summary) • The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. • Before any patient goes on leave, a thorough pre-leave mental state and risk assessment must be conducted and documented. • Upon the patient’s first return from leave, staff must record a timely review of the patient’s condition and any issues arising from the leave.

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.