Dear Ms Serrano Phyllis HART

Further to your letter 16 February 2024 (received 18 October 2024), I am pleased to provide a response under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013, addressing your concerns surrounding the death of Phyllis Hart.

Recorded Circumstances of the Death Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023. On the 21 March 2023, she started to show signs of having a ischaemic leg. On the 27 March 2023, vascular specialist review was requested. You heard evidence that there is no vascular team located on the County Hospital, so the review was delayed for 4 days until the Vascular Consultant was next at the County Hospital. At the review, the decision was made that Mrs Hart was for palliative care only. She passed away on the 8 April 2023

Concerns During the course of the inquest, you felt that evidence revealed matters giving rise for concern. In your opinion, matters for concern are as follows:

1. There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required.

You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

In your opinion, action should be taken to prevent future deaths.

Action Taken The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest seriously and indeed, I am grateful that you have raised your concerns.

1. Our vascular lead has reviewed the concern that you have raised, and we are able to confirm that UHNM provides a 24/7 vascular on-call service which is based at the Royal Stoke Hospital site.

There are also vascular surgeons present at County Hospital every week day (excluding the weekend). Normally, review of the in-patients is led by , Consultant Vascular Surgeon and , Consultant Vascular Surgeon. In addition to this, and (both Consultant Vascular Surgeons) also visit County Hospital on a regular basis.

This lady was referred to the service via the ‘careflow’ system which is usually a slower pathway of referral (ie rather than someone calling the Consultant on-call / on site). Requests via ‘careflow’ emerge on a list on iportal called “vascular inpatient specialty referrals”. The on-call surgeon based at Stoke will then triage these referrals and try to ensure expeditious review at County by a colleague, or instead, arrange to transfer the patient to Stoke.

Whilst the team endeavor to provide prompt reviews for patients in County Hospital, we also rely on accurate information from referrers and prefer, in emergency situations, to receive direct contact rather than electronic.

We will ensure that this information is further conveyed to the wards and clinicians at County Hospital so that they understand that there is always someone from the vascular team to contact, should the need arise.

We do hope that the above information provides assurance that the Trust have taken the concerns raised at the inquest seriously and

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.