Dear Mr Cox Thank you for your letter dated 2 November regarding the inquest touching the death of Trevor Paul Hunking: Since its establishment in 2013, Health Education England has been working to support an increase in the overall general nursing supply: Nurses often go on to train as specialists and it is employers who are responsible for this. In cases where this does happen, although it is the employer's responsibility, HEE is always happy to support them to develop appropriate training: The particular specialty you have identified here is one of those cases. Ongoing workforce supply and retention of the specific specialist cardiac intensive care unit role remains the responsibility of the employer As such, have copied in Danny Mortimer, Chief Executive, NHS Employers and Medical Director; NHS Improvement to further address the matters of concern Yours sincerely RECEIVED Professor Ian Cumming OBE 5 DEC Chief Executive CORONER'S OFFICE Developing people wwwhee nhs Uk for health and hee enqulriesOnhs net @NHS _HealhEdEng healthcare

NHS Employers Brewery Wharf Kendell Street Leeds LS1O 1JR Tel 0113 306 3000 Fax 0113 306 3001 enquiries@nhsemployers org WW.nhsemployers org Mr A J Cox Assistant Coroner: Plymouth, Torbay and South Devon 1 , Derriford Park Plymouth PL6 5QZ 22 December 2016 Dear Mr Cox Mr Trevor Hunking: Regulation 28 report write further to the Regulation 28 report issued to Health Education England (HEE) following the inquest into the death of Mr Hunking_ of HEE proposed to you that my organisation might be able to assist in addressing the issues identified relating to the availability of cardiac specialist nurses, and write to that effect; The present organisational arrangements for the NHS in England are complex but thought it would be useful to summarise the respective roles of the NHS organisations referenced in your regulation 28 report and reply: NHS England has responsibility for specifying and procuring (commissioning) specialist ("tertiary') services such as cardiac surgery from Trusts and Foundation Trusts Health Education England acts on behalf of the Department of Health to ensure availability of education at undergraduate and postgraduate level for the NHS NHS Improvement is effectively the service regulator for Trusts and FTs who provide NHS services in England NHS Employers represents NHS organisations in relation to workforce matters, leading work on their behalf. All four of these organisations hold therefore different responsibilities for supporting the work undertaken by a Trust such as Plymouth Hospitals NHS Trust: In Mr Hunking's case you identified a shortage of specialist nursing staff as a key concern, and am able to identify two ways in which NHS Employers is helping address this issue_ Firstly we are working to ensure that all Trusts and Foundation Trusts are able to access international labour markets. We led a campaign last year for nurses to be placed on the shortage occupation list, which improves the ability of the NHS to recruit nurses from outside the EEA As you will see from the table below; the NHS employs a range of nursing staff from many different parts of the world: Whilst it is the case that a greater proportion of these international colleagues are to be found in London and the South East the numbers employed within the NHS in the South West are comparable to other parts of the country.

HCHS Nurses & Health Visitors nationality by HEE Region, September 2015 4t Othet Toaai Estudbnd 9ik East Hlands 13,791 535 56 | I0I 21231 Ext of Englad Tk Eas of Engbnd 21,920 2,779 1460 213 31,934 KentSutte} Suser Bk Kent Sty - Suxx I0,280 1,991 1559 533 157 24904 Londa M CEE J1K LoxkrH CBE 8,850 1,977 1353 Ba9 21] 15,979 London: North Wet 66K I07 Ldon Horth Wea I5 AT | 2,965 1,419 1579 402 22.606 London" Soun 69k Loncon South IJ,520 2514 1,659 1,747 47] 20462 Noth Ezt 96K Honth Eaa 70,976 2194 Wea 91K Homth Wet 50 02| 1,E63 1643 493
55.794 South WT Jok Squth Wes 21,749 1976 Z0,4u Thant Valky K Taaresvaley 5,757 10 11,515 Meser 06K Wesex
14.165 Loo 9I8
16.978 Wes Mdands Jox Wes Mbnd J104 Lim 1,591 705 30,729 Yort shlie the Humber 9JK Yorkshre tk Humber JI,AcO 953 494 36, 60] I0* 20 J0 4074 5078 607 70r I0 907 100r8 UK DEU Asia Africa Other Since June our work has increasingly focused on the longer term implications for migration policy resulting from the decision to leave the European Union. Secondly we are working with employers in the NHS to ensure that do everything in their power to retain the staff that they do employ, wherever those staff may have come from originally: This programme assists NHS Trusts and FTs in sharing good practice to assist retention of staff. This includes work on flexibility of development and working patterns for staff as well as education and other initiatives have asked that this programme specifically identify whether there are particular actions that might be taken in relation to the retention of cardiac specialist nurses_ Thank you for making me aware of the circumstances surrounding Mr Hunking's death. hope that have been able to give you information which assists in the responses to the regulation 28 report you have issued. Yours sincerely Daniel Mortimer Chief Executive NHS Employers Hotn they

NHS Improvement Medical Directorate 23 December 2016 NHS Improvement Wellington House 133 135 Waterloo Road London SE1 8UG Mr Andrew James Cox Assistant Coroner for Plymouth Torbay and South Devon T 020 3747 000o E: nhsi enquiries@nhs net Her Majesty's Coroner for the County of Devon W improvement nhs uk Derriford Park Derriford Business Park Plymouth PL6 5Q2 Dear Mr Cox Re: Inquest touching the death of Trevor Paul HUNKING write further to the Regulation 28 report issued to Health Education England (HEE) following the Inquest into the sad death of Mr Hunking: Chief Executive of HEE referred your letter to me and have also seen the response from Danny Mortimer, Chief Executive of NHS Employers_ In his response, Mr Mortimer explained the respective responsibilities of the national NHS organisations referenced in your report, which are complex but important background to this issue_ understand from discussions with Plymouth Hospitals NHS Trust that they have taken significant steps locally to maximise their ability to recruit and retain specialist cardiac intensive care nurses, and have a range of local internal accredited training and competency programmes in place: We have worked directly with Plymouth Hospitals since your letter to understand the systems and processes in place and provide assurance on the issues raised. We recognise that nationally intensive care nurses are in short supply, but as outlined above Plymouth have done great deal to address this The Cardiac ICU has 10 funded ICU beds They are supported by a further 6 cardiac level 2 beds_ Currently have a total of 6.6 vacant posts (9%) , of which the majority are at band 5, and have an active recruitment programme_ operate a bank system and agency staff to support any shortfalls to maintain activity. Nationally, NHS Improvement is working with HEE to help address the concerns you raise regarding the availability of cardiac specialist nurses in a number of ways_ Firstly, we are working in collaboration with both HEE and NHS England to review the wider national supply issues of Registered Nurses, and the longstanding impact this has had on recruitment and retention of qualified, specialist, cardiac, general and neuro intensive care nurses_ We are currently reviewing the NHS operational plans including workforce for this year and into next to ensure that system demand is deliverable with safe and sustainable workforce models This work is aligned with NHS England whom also have an important role in supporting the system on workforce such as nursing staff. NHS Improvement is the operational name for the organisation that brings together Monitor; NHS Trust Development Authority, Patient Safety, (he National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. they They

There are other opportunities to work in collaboration with HEE to support the training, development and retention of specialist critical care nurses_ require further development but could include: Ensuring that continuing professional development (CPD) budgets are protected or enhanced to enable providers to fully access Higher Education Institution specialist courses, in numbers that will enable the workforce to grow, rather than stand still: The impact of the reduction in CPD budgets has had a direct impact on the number of staff trusts can support through these essential specialist courses An opportunity to ensure that all Higher Education Institutions offer local accreditation of internal specialist programmes_ An opportunity to undertake an early evaluation of the potential benefit of nursing associates within the critical care environment, with specific competency assessments as a mechanism to support level 2/3 Registered Nurse care_ Retention of all staff is important and alongside NHS England and NHS employers we have a program of work on retention, in areas such as staff wellness and experience, sickness and absence management: These programs promote values in the NHS that support staff to deliver care_ The opportunities outlined above require further development in collaboration with HEE, and NHS Improvement remains committed to working in partnership to explore and develop these opportunities_ Thank you for bringing to my attention the circumstances surrounding Mr Hunking's death hope that the information have provided regarding how we are responding to the concerns you raise is useful: