NHS England

“We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than Emergency Department (ED); from the described circumstances of Ms [name redacted] death, it is not clear whether the UTC was effectively 'gatekeeping' access to an emergency department or not.”

“The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings including the private sector.”

“we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment”

“The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.”

“It is recognised that there is a lack of information being recorded on custody detention logs. The College of Policing Hydra packages are in place to improve this and the NPCC are supportive of this training for custody staff. I understand that Sussex Police have now adopted this training.”

“Guidelines around supporting a LDS Practitioner as to when it is appropriate to undertake a formal mental health assessment when an individual is intoxicated is a matter for the LDS provider.”

“National guidelines are in place in the form of PACE Code C in relation to identifying vulnerability in police custody and the provision of an Appropriate Adult. It is not clear from the information in the report as to why the interviewing officer did not deem the support of an Appropriate Adult for Mr [name redacted] necessary in this case.”

“NHS England has engaged with Newcastle upon Tyne Hospitals NHS Foundation Trust on the concerns raised in your Report. We note that they state they were unable to determine the exact cause of the aortic cannula becoming dislodged, and that the default cannula choice was made for an operation of this nature. We note, however, that following [the deceased]'s death, the Theatre Department have permanently suspended use of the cannula.”

“The NSDR has been in place since December 2019 and acts as a single point of contact when an NHS Trust is experiencing supply disruption and has not been able to mitigate the disruption. Once a disruption has been reported to the NSDR, the Department will then work to help resolve the matter, including by: - liaising with the manufacturer of the product in question for details of the disruption and any recovery plans; - contacting NHS Supply Chain or other distributors/wholesalers that stock the”

“NHS England is currently supporting the development of a range of tools and interventions that will help to upskill more GPs in providing menopause care, and to improve access to treatments that can be helpful.”

“We have reflected on the circumstances surrounding Mrs [name redacted] death and the concerns raised in your report.”

“We also note that they are taking actions to ensure there will always be a member of staff on shift with Immediate Life Support training.”

“NWAS have identified that the call was safely and appropriately triaged as Category 3 with the symptoms provided by [the deceased] on the initial call. It was identified by NWAS at the time that the call was potentially suitable to be supported by clinician callback and details were sent to the Greater Manchester Clinical Assessment Service (GMCAS) for clinical assessment, as per agreed governance processes and to assess if other local services could support [the deceased]'s needs.”