Dear Mr Allen,

Thank you for your letter dated 28 May 2024, in relation to the inquest into the death of Christine Rita Booker. I would like to take this opportunity to express my sincere condolences to Mrs Booker’s family.

I am extremely sorry for the family’s loss, and I am mindful that this will have been more distressing for the family due to the circumstances that led to Mrs Booker’s death, and the subsequent inquest.

Your report details one matter of concern in relation to there being no provision of out of hours interventional radiology at Dorset County Hospital.

You are concerned that patients requiring this potentially urgent and life-saving intervention, who live in West Dorset require transfer to Royal Bournemouth Hospital for treatment. Your concern is that this exposes them to a potentially considerable delay in treatment and therefore an increased risk of death.

We have reviewed the findings of the inquest, and the recommendations as stated in the Preventing Future Deaths report and can confirm that the Trust does not provide a 24/7 emergency service for specialist interventional radiology for embolization. This is a specialised service commissioned by NHS England, provided by University Hospitals Dorset from their site at the Royal Bournemouth Hospital for both Dorset County Hospital and Salisbury Hospital. 24/7 specialised interventional radiology services are not available in every local hospital because they are delivered by specialist teams who have the necessary skills, experience and volume of work to maintain safe standards of care across wider geographical areas.

The commissioned pathway of care, for those requiring emergency specialist interventional radiology who attend Dorset County Hospital, is for ‘blue light transfer’ to the Royal Bournemouth Hospital, or other tertiary centre, via the ambulance service or in time critical situations by helicopter.

10 June 2024

PRIVATE AND CONFIDENTIAL

Dorset County Hospital Williams Avenue Dorchester Dorset DT1 2JY

Therefore we understand that the regulation 28 notice sent to Dorset County Hospital should be addressed to NHS England as the service commissioner, and we have also made them aware of this (NHS England’s regional medical director is also copied into this response letter).

The Trust is committed to continuous learning from any incident to strengthen the services for which it is responsible. Therefore we are carrying out an investigation of the management of this case as it pertains to Dorset County Hospital and will request sight of the report from the Winterborne Circle Hospital. In conjunction with UHD we are auditing the transfer times for interventional radiology between the two sites and our compliance with ‘decision to transfer’ standards. We will continue to monitor the service to ensure timely clinical decision making and access to services are in place for all current and future patients.

I hope that the arrangements detailed provide you with assurance that the Trust has mechanisms in place to learn from and monitor our services as well as clinical decision making, so that we ensure patients have access to timely and safe care.

Finally, I would like to end by reiterating our sorrow and condolences to the family of Mrs Booker for their loss.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Christine Rita Booker who died on 24 February 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 October 2024 concerning the death of Christine Rita Booker on 24 February 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Christine’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Christine’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Christine’s family or friends. I realise that responses to Coroner’s Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised the concern that there is no out of hours interventional radiology at Dorset County Hospital and that patients requiring this intervention who reside in the area must be transferred to the Royal Bournemouth Hospital, exposing patients to a potentially significant delay in the provision of urgent and life-saving treatment.

In preparing this response, colleagues within the Clinical Reference Group (CRG) for Vascular Disease have been consulted.

Orthopaedic procedures do sometimes lead to life-threatening complications such as bleeding, as they sadly did for Christine. They are also often being carried out in private hospitals where there is no vascular cover. It is important to identify such complications early, resuscitate and arrange transfer to a site where definitive and life-saving vascular intervention can be performed. The transfer should be to a site (usually a vascular hub) where 24/7 vascular intervention is available, and this should include both interventional vascular radiology and vascular surgery.

Based on the information provided in your Report, NHS England is unable to provide further comment on the care provided to Christine following her procedure, and her transfer to Royal Bournemouth Hospital. It is not clear to NHS England whether the hip replacement procedure had been commissioned and funded by the NHS. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 December 2024

My South West regional colleagues have been engaging with NHS Dorset Integrated Care Board and NHS England Direct Commissioning South West, to gather further information in this matter.

Dorset Integrated Care Board advise that there is a well-practiced hub and spoke model with the Royal Bournemouth Hospital for vascular services, as well as clear pathways for private provider transfer. They advise that a full interventional radiology service at Dorset County Hospital would likely be unsustainable.

NHS England continues to seek further details on the issues surrounding Christine’s care and the matters raised in your Report from colleagues in the South West. We are happy to update the Coroner on the information received in due course. However, we remain of the view that the concerns raised by the Coroner in respect of the circumstances of Christine’s death are more appropriate for the Trusts to address.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Christine, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.