Epilepsy, 19 Sep 2013 – 19 Jun 2026
Epilepsy-related Prevention of Future Deaths reports
All dates19 Sep 2013 – 7 Sep 2026
Select SUDEP or Non-SUDEP to filter concerns and reports. 3 reports could not be assigned and remain in All only. Counts are PFD reports, not deaths.
About this dataset
We searched all 6,433 reports in the published corpus using a fixed text-search method, then assessed 317 candidates against source-based inclusion criteria. Ninety reports were included. Epilepsy had to be materially relevant to the death or a substantive coroner’s concern; incidental mentions were excluded.
Eligibility and SUDEP assignment were assessed with GPT-5.6 Sol and checked for valid source quotations. Assignment uses a balance-of-probabilities threshold: SUDEP or non-SUDEP must be more likely than not on the report’s evidence. The exact term SUDEP need not appear. Genuinely unclear eligible reports remain in All only. These are model-assisted documentary assessments, not independently validated clinical diagnoses.
The search can miss reports with sparse terminology or incomplete source text. This dataset does not represent all epilepsy deaths. Recurring concerns and responses are taken from the existing published evidence. Published corpus snapshot: 7 September 2026. Cohort selection updated 5 November 2026. The title shows the first and last included reports’ publication dates.
Reports over time
Matching reports published each year within the selected date range.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Matching reports sent to each recipient.
Most commonly raised concerns
All classifications 90 reports 19 Sep 2013 – 7 Sep 2026
- Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.9 reportsSelected
- Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.7 reportsSelected
- Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.6 reportsSelected
- Failure to ensure clinical investigation results are reliably available, interpreted and acted uponRecurring deficiency in the end-to-end management of clinical investigation results, including their availability, transmission, checking, review, interpretation, follow-up and escalation when needed.4 reportsSelected
- Inadequate driver licensing controls for road safetyDriver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards.4 reportsSelected
- Inadequate staff competence to provide first aidReports identify an unsafe first-aid capability condition across healthcare, care, custody and other staff. The recurring concern is the unreliability of staff competence to recognise emergencies and provide appropriate first aid, rather than any single training, refresher, assessment or practical-performance failure.4 reportsSelected
- Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.4 reportsSelected
- Failure to communicate clinically important information reliably between care servicesRecurring concern that clinically important guidance, decisions and patient information are not kept accurate, current and available to the clinicians and emergency services who need them.3 reportsSelected
- Failure to provide required medication promptly when clinically neededThe anchor identifies delayed prescribing of a patient's usual medication after an unexpected admission, while another report identifies delayed prescribing and non-provision of urgent therapeutic medication. These support a recurring concern about timely provision of clinically required medication rather than only the anchor's admission or prescribing-step failure.3 reportsSelected
- Failure to provide timely clinical follow-up after medication prescribingPrescribed medication is not reliably followed up for effectiveness, safety, collection, adherence and patient response.3 reportsSelected
- Failure to seek medical attention when a person's condition warrants itReports identify an unreliable escalation control in which care staff or other responders do not promptly seek medical or paramedic assistance when a person's injury, pain, fall or deterioration warrants clinical attention.3 reportsSelected
- Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crisesReports identify insufficient police training to recognise and respond safely to mental-health crises and behaviour-related medical emergencies.3 reportsSelected
- Insufficient qualified healthcare staffing capacityHealthcare services lack enough appropriately qualified staff to provide the required clinical coverage and patient care safely for the workload, acuity and specialist needs.3 reportsSelected
- Unreliable DVLA medical fitness notification arrangementsThe anchor identifies limited professional awareness and uncertain effectiveness of guidance for notifying the DVLA about medically relevant driving risks. A different report identifies clinicians failing to advise patients with cough syncope to stop driving and notify the DVLA, while another identifies failure to notify the DVLA of relevant medical conditions. These support the named DVLA medical-fitness notification process rather than guidance awareness alone.3 reportsSelected
- Unreliable communication of patient-care information between clinical staffClinical staff responsible for the same patient's care do not reliably exchange relevant information about care, treatment and risk.3 reportsSelected
- Unreliable healthcare patient transfer processesHealthcare transfers do not reliably provide the procedures, responsibility, documentation and clinical information needed for safe movement and continuity of care.3 reportsSelected
- Unreliable mental health referral pathwaysReports identify different failures within the mental health referral process, including referrals not being made when indicated, received referrals not being actioned, and frontline practitioners lacking clarity about when and where to refer. These support a recurring concern with the reliability of mental health referral pathways rather than any single referral or awareness failure.3 reportsSelected
- Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.3 reportsSelected
- Unsafe interoperability between prison custody and healthcare proceduresReports identify failures in the bounded interface between prison custody, contracted custody providers and healthcare services, where procedures, responsibilities and safety-relevant information do not operate together reliably.3 reportsSelected
- Electronic patient records failing to make relevant clinical information available and actionableRecurring concern that electronic patient-record systems do not reliably present, preserve, share or prompt action on clinically relevant information across the patient’s care.2 reportsSelected
- Failure to communicate safety-critical care information effectively between care providers and familiesReports identify unsafe communication between care providers and families, including failures to convey risks, care instructions, concerns or other information needed to support safe care and decision-making.2 reportsSelected
- Failure to conduct required welfare checks on people in distressThe anchor identifies a risk that care home staff will not check a resident in distress, while a different canonical report identifies failure to conduct a later welfare check on a person left in potential medical distress. Together these support a recurring concern about welfare checks not being completed when a person may require assistance.2 reportsSelected
- Failure to ensure safe prisoner transfersRecurring concern that the end-to-end prisoner transfer process is unreliable, leaving transferred prisoners exposed to unmanaged risks or interruptions in essential support.2 reportsSelected
- Failure to identify and address recurring safety issues through organisational learningDifferent reports identify failures of reporting, review and learning arrangements to retain, recognise and address substantive or recurring patient-safety issues, rather than merely failures to complete one specific corrective action.2 reportsSelected
- Failure to reliably document the rationale for consequential decisionsDifferent reports identify missing or inadequate records explaining the rationale and evidential basis for consequential decisions, including the anchor’s crucial decisions and comparable mental-capacity, NRPF and transfer decisions. The shared concern is unreliable rationale documentation for decisions that affect safety, accountability and continuity of care, rather than any one decision type or record system.2 reportsSelected
- Failure to reliably learn from medication incidents and implement safeguardsThe medication incident learning process is unreliable: incidents are not consistently followed up or reviewed to identify, communicate and implement safeguards that protect patients from recurrence.2 reportsSelected
- Failure to reliably recognise and respond to acute clinical deteriorationClinical deterioration is not reliably recognised, monitored, escalated and acted upon with the urgency it requires.2 reportsSelected
- Failure to reliably refer patients to required specialist servicesThe anchor identifies a required physiotherapy referral that was not completed. A different report identifies delayed referrals to physiotherapy, occupational therapy, dietetics and Parkinson’s specialist services. Together these support an end-to-end concern with required specialist referrals not being made promptly and reliably, rather than a concern limited to one physiotherapy referral.2 reportsSelected
- Failure to secure and control medicationReports identify medication as remaining accessible, unsecured or inadequately controlled, creating risks of misuse, overdose, theft or access by people other than the intended patient.2 reportsSelected
- Inadequate control of illicit substance use and supply in secure institutionsThe anchor identifies an ongoing failure to mitigate illicit substance entry, distribution and use in a secure hospital, while assertions from different reports identify continuing illicit-drug influx, widespread access and weak supply-reduction controls in prisons. These distinct manifestations support a bounded concern about controlling illicit substances in secure institutional settings, rather than only room searches, drug testing or a prison-specific strategy.2 reportsSelected
- Inadequate controls on contraband mobile phones in prisonsDifferent reports identify failures in the prison control system for preventing and mitigating access to contraband mobile phones, including their easy availability to prisoners and their use to facilitate drug dealing and other prison-security risks.2 reportsSelected
- Inadequate recording of medication prescribing decisionsReports identify unreliable medication prescribing records that can obscure prescribing status, rationale, changes or safety-critical decisions and thereby allow unsafe medication to be prescribed or administered.2 reportsSelected
- Incomplete clinical history-takingReports identify an unsafe clinical assessment condition in which relevant patient history is not obtained sufficiently to support recognition of symptoms, risks and appropriate care.2 reportsSelected
- Unreliable Care Programme Approach care coordinationReports identify different failures within the named Care Programme Approach, including the absence of a structured medication review and failures to allocate coordinators, complete required reviews, maintain care plans and follow up patients. Together these support a recurring concern with the reliable operation of CPA care coordination rather than medication review alone.2 reportsSelected
- Unreliable RIO clinical-record functionsThe anchor identifies an unclear timeliness standard for RIO entries, while different reports identify failures of RIO to support complete information capture, cross-team access and usable observation records. Together these support a recurring concern with the reliability of the named RIO clinical-record system rather than only one entry-timing or documentation manifestation.2 reportsSelected
- Unreliable access to emergency communicationReports identify failures in dedicated emergency communication arrangements that can delay summoning or contacting emergency help.2 reportsSelected
- Unreliable communication of critical medication information to GPsRecurring deficiency in the medication-information exchange process between services and GPs, including information needed to maintain supplies, assess prescribing safety and support continuity of treatment.2 reportsSelected
- Unreliable escalation by care staff for required medical attentionCare staff do not reliably recognise and escalate deterioration, pain or other safety concerns to obtain timely medical assessment or advice.2 reportsSelected
- Unreliable implementation of medication changesReports identify different failures in the medication-change process, including failure to act on a prescribed reduction, failure to ensure carers acknowledge changes, and difficulty implementing specialist-directed changes accurately. Together these support the wider unsafe condition that medication changes are not reliably implemented across prescribing, communication and follow-up controls.2 reportsSelected
- Unreliable inter-agency information sharing for coordinated careThe anchor identifies absent agreed communication means and inaccessible shared patient information between mental health agencies. Other canonical reports identify relevant risk information not being shared between agencies and poor inter-agency information sharing preventing coordinated care, supporting a recurring concern with the reliability of inter-agency care information sharing rather than only the anchor's repository or communication-channel failure.2 reportsSelected
- Unreliable management of medication doses not takenThe anchor identifies missing guidance for monitoring prescribed medication that self-administering patients do not take when dispensed. A different report identifies inconsistent procedures for responding when service users refuse or do not take medication. Together these support a recurring concern with the reliability of detecting, monitoring and escalating omitted or refused medication doses, rather than a concern limited to one guidance document or one home's procedure.2 reportsSelected
- Unreliable medication dosage verification and communicationReports identify unsafe failures to ensure that medication dosages are accurately verified, clarified and communicated across prescribing, dispensing and administration activities.2 reportsSelected
- Unreliable observation of people in custodyThe anchor report identifies failure to transfer and replicate medically required observation levels when a detained person moves into GEO AMEY custody, while a different report identifies uncertainty about whether the correct observation level, including constant watch, was provided to a person in prison custody. Together these support a recurring concern about the reliability of the custody observation process rather than only one handover or level-setting failure.2 reportsSelected
- Unreliable recording of required observations in care and custodyDifferent reports identify inaccurate, delayed, anticipatory or falsified records of required observations, including 15-minute observations in prison custody and patient-care settings. The shared unsafe condition is that observation records do not reliably reflect when and how observations were actually conducted, rather than any one observation frequency, recording location or electronic system.2 reportsSelected
- Unreliable review and action on clinically significant incoming correspondenceReports identify failures across the incoming clinical-correspondence process, including failure to identify GP medication-review requests, failure to bring action-requiring correspondence to medical staff, and correspondence being filed without GP review or action. The shared unsafe condition is that clinically significant correspondence may not reliably reach the responsible clinician or trigger the required clinical response.2 reportsSelected
- Unreliable safety CCTV monitoring systemsDifferent reports identify failures in the operation of CCTV used as a safety control, including absent staff access arrangements, inadequate coverage, non-working cameras, insufficient monitoring and unclear staff instructions. Together these support the reliability of safety CCTV monitoring as the parent concern rather than any single access, coverage, equipment or training failure.2 reportsSelected
- Unreliable urgent mental health referral and assessment pathwaysUrgent mental-health referral pathways do not reliably secure timely access, coordination and specialist assessment.2 reportsSelected
- Unreliable welfare-check processes for people whose health is of concernThe anchor identifies unclear purpose and use of the welfare sheet for monitoring prisoners whose health is of concern. A separate report identifies inconsistent criteria for what constitutes a welfare check and when it is recorded. Together these support a recurring concern with the reliability of the bounded welfare-check process, rather than only the sheet or recording component.2 reportsSelected
- Unsafe cell-sharing decisions for prisonersRecurring deficiencies in the prison cell-sharing risk system can leave prisoners exposed to unsafe pairings or prevent them from understanding changes affecting their cell-sharing status.2 reportsSelected
- Unsafe medication prescribingReports identify unsafe prescribing decisions in which the medication, indication, dose or relevant clinical circumstances are not adequately evaluated before prescribing.2 reportsSelected
All reports in this date range
19 Sep 2013 – 7 Sep 2026 · 90 reports
Showing all concerns and their linked actions and positions from reports in this date range. Select a recurring concern above to narrow the evidence.
Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.
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Concerns raised2
Failure to provide required one-to-one nursing care
Critically stretched healthcare resources
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.
Stated by Department of Health and Social Care
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Concerns raised9
Failure to ensure truthful observation records
Failure to maintain QEH staff awareness of the limits of prison healthcare
Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
Failure to prescribe and administer medication at the correct dose
Failure to ensure safe and clearly understood medication-system operation
Failure to record the cell-entry escalation process in policy
Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
Failure to complete required patient observations
Unavailability of larger disabled cells adapted for constant watch
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Insufficiently robust arrangements for ensuring that drivers with serious conditions have their licences properly reviewed
Failure of drivers to self-report potentially significant conditions to the DVLA
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Deliver educational sessions for healthcare professionals encouraging direct DVLA notifications when patients cannot or will not notify themselves.
Stated by MP, Minister for Local Transport -
Action
Continue engagement with regulatory bodies, clinical networks and healthcare professionals to identify barriers to DVLA notifications.
Stated by MP, Minister for Local Transport -
Action
Raise public awareness of the legal duty to notify the DVLA about medical conditions and the consequences of non-notification.
Stated by MP, Minister for Local Transport
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Action
Reinforce existing General Medical Council guidance on notifying the DVLA when patients continue driving despite advice to notify.
Stated by MP, Minister for Local Transport -
Action
Review and improve self-declaration forms and associated notification processes.
Stated by MP, Minister for Local Transport
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Concerns raised3
Failure to convey information about critically depleted seizure medication to the GP
Failure to prioritise prescriptions for same-day supply of critically depleted seizure medication
Difficulties obtaining sufficient quantities of epilepsy medication for continuous access
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
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Action
Introduce a formal escalation process prioritising requests for critical medicines, including same-day clinical review and urgent clinician alerts.
Stated by Sundon Medical Centre -
Action
Train reception and administrative staff to recognise critical medicines, manage split-strength requests, escalate concerns and verify communications.
Stated by Sundon Medical Centre -
Action
Review implementation of the medication-safety changes and monitor compliance with urgent-medicine, dosage-wording, written-request and escalation procedures.
Stated by Sundon Medical Centre
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Action
Clearly communicate the urgent status of critical-medication prescriptions to pharmacies to support prompt dispensing.
Stated by Sundon Medical Centre -
Action
Consider repeat dispensing, batch prescribing, or one-off reserve prescriptions for suitable patients at risk of running out of critical medication.
Stated by Sundon Medical Centre -
Action
Work with the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
Stated by Department of Health and Social Care -
Action
Inform epilepsy patients about the Charlie Card emergency-supply self-advocacy tool.
Stated by Sundon Medical Centre -
Action
Provide clear patient information about prescription processing and pharmacy dispensing times through the website and reception.
Stated by Sundon Medical Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
NHS England and delegated Integrated Care Boards commission and performance-manage general practice, including addressing persistent performance concerns.
Stated by Department of Health and Social Care
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Position
Existing urgent-supply arrangements, including pharmacist emergency supplies and NHS 111 referrals, provide routes to obtain urgently needed medicines.
Stated by Department of Health and Social Care -
Position
Existing regulations and NHS pharmacy terms require community pharmacies to dispense NHS medicines with reasonable promptness and notify patients of delays.
Stated by Department of Health and Social Care
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Concerns raised8
Insufficient medication verification during care-needs assessment
Failure to prevent administration of GP-discontinued medication
Failure to follow up medication incidents for learning affecting vulnerable patients
Failure to provide complete current medication and stop-date information during care handover
Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Inaccurate or incomplete recording of medication administration
Failure to liaise with the community pharmacy about regularly dispensed medication
Risk of discontinued or essential seizure-control medication being incorrectly administered
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.15
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Action
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation Trust -
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation Trust -
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation Trust
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Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation Trust -
Action
Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Stated by Sussex Community NHS Foundation Trust -
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd. -
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd. -
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd. -
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation Trust -
Action
Complete a formal review of the MAR chart SOP for UCR and Home First services.
Stated by Sussex Community NHS Foundation Trust -
Action
Deliver staff briefings and training aligned with the revised MAR chart SOP after approval.
Stated by Sussex Community NHS Foundation Trust -
Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation Trust -
Action
Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Stated by Coastal Homecare (Hove) Ltd. -
Action
Require all staff to complete additional Epilepsy Awareness training.
Stated by Coastal Homecare (Hove) Ltd. -
Action
Attend Local Authority training on epilepsy awareness, seizure management, and buccal midazolam.
Stated by Coastal Homecare (Hove) Ltd.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation Trust
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Concerns raised3
Failure to maintain the gate house at a security level that restricts entry of illicit materials
Failure to maintain prison-block windows at a security level that restricts entry of illicit materials
Delays and non-occurrence of scheduled morning welfare checks due to lack of staff
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
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Action
Plan expansion works for a new Gate House and refurbishment of the existing Gate House to accommodate Enhanced Gate Security.
Stated by Clyde & Co Claims LLP -
Action
Use specialist screening equipment routinely to screen staff, professional visitors and social visitors entering the prison.
Stated by Clyde & Co Claims LLP -
Action
Fund and deploy additional external dog patrols to reduce contraband throwovers and support searching.
Stated by Clyde & Co Claims LLP
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Action
Develop a business case seeking funding for staffing and additional dogs to support searching seven days a week during core hours.
Stated by Clyde & Co Claims LLP -
Action
Expand the Special Searching Team to increase the frequency and quality of staff and visitor searches.
Stated by Clyde & Co Claims LLP -
Action
Deliver the phased replacement of vulnerable prison windows to reduce contraband ingress.
Stated by Clyde & Co Claims LLP -
Action
Issue updated welfare-check procedures requiring physical checks during morning unlock.
Stated by Clyde & Co Claims LLP -
Action
Operate enhanced daily compliance checks using CCTV review, rotational unit sampling, issue escalation and management follow-up.
Stated by Clyde & Co Claims LLP -
Action
Update initial and refresher training to instruct officers on positive-response welfare checks during unlock.
Stated by Clyde & Co Claims LLP -
Action
Review welfare-check compliance and trends through monthly multidisciplinary Safety Meetings.
Stated by Clyde & Co Claims LLP -
Action
Reissue written instructions and reminders on correct unlock procedures and welfare checks, including communication through safety meetings.
Stated by Clyde & Co Claims LLP -
Action
Amend residential wing ledgers to require daily recorded welfare checks, including weekends.
Stated by Clyde & Co Claims LLP
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
A temporary gatehouse extension was not pursued because existing interim searching measures were considered a better use of finances, though less comprehensive.
Stated by Clyde & Co Claims LLP
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Position
HMPPS must approve and fund building-design changes, while G4S is contracted only to manage and maintain the existing facility.
Stated by Clyde & Co Claims LLP -
Position
Window replacement cannot be completed widescale or faster because approved suppliers, specialist contractors, prisoner relocation and security logistics constrain delivery.
Stated by Clyde & Co Claims LLP -
Position
Welfare checks could safely be conducted by one officer, and there was no requirement for officers to conduct them in pairs.
Stated by Clyde & Co Claims LLP
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Concerns raised2
Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Lack of national pathway guidance for call handlers on assessing how cold the body is
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.
Stated by NHS England
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Concerns raised5
Use of drones to deliver drugs and other contraband into prison
Easy availability of new psychoactive substances in prison
Easy availability of mobile phones in prison
Failure to hold statistics on drug-related deaths in prisons
Failure to protect vulnerable prisoners from forced testing of illegal drugs
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
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Action
Deliver staff upskilling to improve responses to drone activity affecting prisons.
Stated by HM Prison and Probation Service -
Action
Conduct vulnerability assessments across the prison estate to understand drone risks and inform mitigation plans.
Stated by HM Prison and Probation Service -
Action
Invest over £40 million in physical security across 34 prisons, including anti-drone measures at more than 15 priority prisons.
Stated by HM Prison and Probation Service
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Action
Develop comprehensive guidance for responding to drone activity affecting prisons.
Stated by HM Prison and Probation Service -
Action
Provide trace-detection equipment to all public sector prisons to identify drugs on physical items.
Stated by HM Prison and Probation Service -
Action
Operate X-ray body scanners in all adult male closed prisons to detect and deter internally concealed illicit items.
Stated by HM Prison and Probation Service -
Action
Equip 54 priority establishments with enhanced gate security, including metal detectors and X-ray baggage scanners, to screen staff and visitors.
Stated by HM Prison and Probation Service -
Action
Examine all drug-related deaths through the early learning review process and use findings and recommendations to address safety concerns.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
More definitive drug-related deaths statistics cannot currently cover later years because incomplete coroner data would reduce result quality.
Stated by HM Prison and Probation Service
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Position
HMPPS cannot publish a specific drug-related deaths category because such cases cannot be identified accurately within required publication timescales.
Stated by HM Prison and Probation Service
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Concerns raised2
Failure to consistently discuss SUDEP with patients with epilepsy
Lack of SUDEP training for doctors
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Medical schools, royal colleges and the GMC determine and oversee medical education curricula and standards, rather than the department.
Stated by Department of Health and Social Care
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Concerns raised1
Delays in releasing ambulances from emergency departments
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
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Action
Appoint a dedicated Associate Director of Clinical Operations to strengthen senior clinical leadership for patient flow and handover-delay escalation.
Stated by Aneurin Bevan University LHB -
Action
Continue the focused Handover 45 initiative to reduce ambulance handover delays and sustain performance improvements.
Stated by Aneurin Bevan University LHB -
Action
Embed the national optimal hospital flow framework, including standardized board rounds, across acute and community hospitals in Gwent.
Stated by Aneurin Bevan University LHB
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Action
Review the Emergency Pressures Escalation Policy against NHS Wales urgent and emergency care escalation guidance.
Stated by Aneurin Bevan University LHB -
Action
Maximize capacity of the dedicated Transfer and Discharge Lounge at Grange University Hospital.
Stated by Aneurin Bevan University LHB -
Action
Use weekly scrutiny panels and improved system escalation to focus on longest-staying patients.
Stated by Aneurin Bevan University LHB -
Action
Appoint six additional whole-time-equivalent Emergency Department consultants to increase assessment and treatment capacity.
Stated by Aneurin Bevan University LHB -
Action
Develop a criteria-led discharge approach using agreed clinical criteria for timely and safe discharge.
Stated by Aneurin Bevan University LHB -
Action
Review the internal Immediate Release Protocol for compliance with WAST’s revised purple 999 response.
Stated by Aneurin Bevan University LHB -
Action
Refresh weekly whole-system flow oversight with senior executive chairing and action plans for emergency care and ambulance handover delays.
Stated by Aneurin Bevan University LHB -
Action
Operate the larger transfer lounge opened at Grange University Hospital to support earlier transfer of patients from the Emergency Department.
Stated by Aneurin Bevan University LHB -
Action
Develop a digital platform showing patient status at each pathway stage to improve patient flow.
Stated by Aneurin Bevan University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
WAST was responsible for contacting the Health Board through approved routes to request release of a delayed ambulance vehicle.
Stated by Aneurin Bevan University LHB
