NHS England

“NHS England is also investing £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. This includes a culture of care improvement programme which is being co-produced with patients, carers and families with lived experience.”

“I have asked that NHS England is sighted on the Trust's response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken.”

“We will request these be addressed as soon as possible”

“The Trust now has 3 consultant sessions per week for neurology consultants to provide advice and guidance for GPs. This is a new facility which was introduced in May 2023, for GPs to access advice prior to or instead of referring for an outpatient clinic”

“I note that the Trust aims to see urgent referrals within 4 weeks and has committed to making further improvements across its neurology service.”

“We have established Clinical Networks and regional delivery groups for mental health across NHS regions to support commissioning of effective services.”

“NHS England will also engage with Medical Priority Dispatch System, the suppliers of the alternative telephone and digital triage system used by ambulance services in England, to review their processes for assessing adrenal insufficiency.”

“We note your suggestion that the issues raised in your report should be considered in the development of our new guideline on adrenal insufficiency, particularly that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress.”

“recommend that all health and care providers ensure their organization has put processes in place to ensure the four actions on the National Patient Safety Alert have been addressed.”

“We are aware that increased body temperature can be a trigger for seizures in Dravet's syndrome and that these seizures may be of a complex nature (lasting longer than 15 minutes or occurring again within 24hr”

“We have taken an action to make all the medical directors and lead paramedics of UK ambulance services aware of the circumstances of [the deceased]' death and have asked them to review the JRCALC guidance and any local pathways or guidance in relation to decisions around conveying children after seizures.”

“We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of [the deceased]' death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6). CG137 has since been replaced by our guideline”

“we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.”

“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”

“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”

“the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.”

“response, are providing the required guidance and training to all medical professionals who hold these important powers”

“I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.”