Dear Ms Mutch

Re: Inquest in to the death of Mr Joseph Cheetham

I am writing in relation to the further information you requested at the conclusion of · the inquest touching on the death of Mr Joseph Cheetham, which was held on 22 September 2020. I would like to thank you for highlighting your concerns and giving the Trust an opportunity to respond. The Associate Medical Director, and Associate Nurse Director of the Medicine and Clinical Support Business Group have investigated these matters on my behalf and I can now share with you the following information. ·

I understand from our inquest team, that you requested further information on two points. I have taken each point in turn, and trust this approach is satisfactory to you.

Steps taken to support meal times

The Trust has in place approved policies for protecting meal times. This includes restricting visiting, visual aids to identify people who require extra support and minimising clinical interactions during meal times. Patients are regularly reviewed using the Malnutrition Universal Screening Tool (MUST) score for nutrition and hydration. We monitor nutrition and hydration through nursing quality metrics and the ward accreditation scheme. Trained volunteers also support patients with their nutrition needs across the organisation-. In addition, the corporate nursing team has completed a mini accreditation for nutrition and hydration compliance on all the inpatient wards across the Trust. This process identified many areas of good practice and areas in need of more support and guidance.

All ward areas have received a dedicated 'seven minutes briefing' session focused on patient nutritional standards with key points also being displayed in ward areas. The Trust continues to promote an annual malnutrition awareness week aimed at raising the profile of the importance of good nutrition and hydration in the Gare and treatment of patients. · ·

At a local level on Ward A11, an action plan has been devised in order to highlight the improvement required to deliver consistent quality patient care to the high standards we set for ourselves. These actions include: monitoring completion of the MUST score; refresher training for staff; compliance with role specific training for staff; additional support from dieticians and the Quality Matron; visibility of mealtime standards and expectations in ward areas; reinforcing communication at shift handover regarding patients with nutritional needs; monitoring staff compliance through appraisal and audits.

Guidance on the administering of medication following a SALT assessment

The Trust Speech and Language Team (SALT) has in place Trust-wide approved guidance, which has been developed to ensure patients are appropriately assessed for swallowing ability including the identification of specific problems occurring during the oral and pharyngeal stages of swallowing.

The stroke specialist nurse has led a dedicated project aimed at · increasing awareness amongst clinical staff of the important role of patient positioning in the respect of naso-gastric tubes used for the administration of medication and nutrition. This project promotes the sharing of best practice guidance and associated information from SALT via teaching session.

I have enclosed several documents for your information that detail best clinical practice which are used across the Trust

• Seven minute briefing regarding supported mealtimes This briefing document has been shared with all .staff across the Trust. The briefing is disseminated to every ward area in the hospital with the aim to highlight important factors and promote discussion within teams. It is displayed in all wards as a reminder of the expectation from staff for our patients.

• Meal time standards These standards are · displayed on the ward information boards, with · information for all staff to read in regards to expectations on the ward. During the staff safety huddle performed twice daily, all staff are made aware of patients with specific dietary requirements and needs, highlighting 'at risk' patients.

• Green apple card The card was introduced as a trial in order for all staff to be aware of which relatives had been authorised to attend the ward at mealtimes, following discussion with the senior nursing team. This currently is on hold due to the visiting restrictions due to the pandemic. The rationale behind the card, is to ensure ease of access for the relatives of patients identified as requiring assistance at mealtimes.

In addition there is also a Trust intranet microsite for Nutrition and Hydration which staff can access at any time to find up to date information and guidance to support

our' patients. The site contains information, advice, policies and procedures to support and educate staff. ' I trust that this answers the queries raised following the inquest. If you have any further queries please do not hesitate to contact me.

Chief Executive

Enc

Dear Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Joseph Michael Cheetham, date of death: 22 January 2020.

Thank you for your Regulation 28 Report dated 30 September 2020 concerning the death of Joseph Michael Cheetham on 22 January 2020. Firstly, I would like to express my deep condolences to Mr Cheetham’s family.

The regulation 28 report concludes Mr Cheetham’s death was a result of 1a) Hospital acquired pneumonia; 1b) Reduced mobility on a background of left total hip replacement dislocation; ii) Vascular dementia, Paroxysmal atrial fibrillation, Aspiration pneumonia.

Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding

Point 1 Transfer of patient to the Emergency Department despite GP booking direct admission to ward

It is recognised that there are often cases where patients are booked directly by a GP to a hospital ward or department (often a medical assessment unit). Due to the higher levels of demand on hospitals, patients are often re-directed to attend the emergency department due to a lack of capacity on the wards. This places further pressure on often already busy emergency departments and can lead to extended wait times for admission to the receiving ward.

As part of the Greater Manchester Urgent Transformation Programme, we have developed and agreed a set of principles for all localities to adopt which will help to prevent a re-occurrence of this. The agreed principles are as follows:

1. All HCP referrals (self-presenting or by ambulance) are accepted direct by the speciality and only clinically unstable patients or those requiring a time critical intervention are advised to attend ED.
2. All clinically stable patients referred to a speciality are assessed by that speciality in a designated assessment area and not in the ED.
3. Same Day Emergency Care (SDEC) is provided across all major specialities, 12 hours a day, Monday – Friday. Weekend SDEC services, if not currently operational, should be modelled and developed to meet demand.

All localities within GM are now in the process of implementing these. In addition to this, further work is being undertaken to help reduce the numbers of attendances to emergency departments. As highlighted in previous correspondence, GM has agreed to a new approach which will incorporate two elements:

• Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department
• A new pre-Emergency Department triage and streaming system

Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go to an Emergency Department. A large proportion of patients will receive early, local clinical assessment prior to being referred which will help ensure safety. We estimate that the new models of care will reduce Emergency Department attendances by around 900 per day across Greater Manchester.

I can confirm that all localities within GM have now gone live during the last 3 weeks with their services. A new national campaign to promote 111 First will be launched in early December which will encourage patients to call 111 before deciding to attend an emergency department.

All hospital trusts in GM will also be implementing a new national data set for recording information which will help to monitor the impact of the agreed changes over the longer term (the Emergency Care Data Set – ECDS). Trusts are required to have this fully implemented by April 2021.

Stockport have also confirmed that they have recently submitted an Outline Business Case which will see a new three storey capital build able to receive referrals direct from primary care with an aim to care for 45% of patients within Same Day Emergency Care by the end of 2023/24.

Point 2 – delay in discharge due to waits for a package of care

As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within Greater Manchester. The purpose of the guidance is to improve the flow of all patients being discharged from acute care and to help ensure patients’ needs are assessed in the home or usual place of residence – not in the hospital. If it is not

possible to disharge the patient to their usual place of residence then they are now transferred to a discharge to assess bed within the community. To help reduce delays, and improve the operation of the pathways, it has been agreed that the following elements of the guidance are required to be implemented by all localities:

• Adoption of a single GM Discharge to Assess Referral Form
• Triage of discharge to assess referrals within 30mins
• Adherence to the guidance for COVID 19 testing for discharge and PPE requirements
• The supply of 2 weeks medication supplies at the point of discharge from an acute hospital
• Operation of a next day follow up process following discharge (localities to determine how this is delivered)

The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domicillary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.

Stockport Trust have also implemented the following to help improve discharges:

• An Integrated Transfer Team that comprises nurses, ward trackers, mental health practitioner, Age UK and a virtual homeless practitioner.
• A Discharge to Assess hub with nursing and therapy staff
• A trusted assessor care home team
• Extra therapy staff in the Bluebell Discharge to Assess unit to provide enhanced therapy support and to improve flow.

I hope this response is satisfactory and provides sufficient assurance on the work we have undertaken to help mitigate the risk of future deaths.

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.

From Edward Argar MP Department Minister of State for Health of Health & 39 Victoria Street London Social Care SW1H OEU 020 7210 4850 Your Ref: Our Ref:] Ms Alison Patricia Mutch HM Senior Coroner; South Manchester HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG t0 December 2020 2 Mhsa Thank you for your letter of 30 September to Matt Hancock about the death of Joseph Michael Cheetham: am replying as Minister with responsibility for NHS operational performance, including emergency care and winter planning and am grateful for the additional time in doing so. Firstly, would like to offer my sincere condolences to Mr Cheetham's family and loved ones: was very saddened to read about the lengthy delay Mr Cheetham experienced at the Emergency Department at Stepping Hill Hospital, Stockport, and that a package of care to support his discharge from hospital was not available once Mr Cheetham was medically ready: This falls short of the high standards of care we expect from the NHS and that the NHS strives so hard to deliver and it is important that we take the learning from Mr Cheetham's experience to improve the quality and safety of NHS care: am aware that this is the fourth Prevention of Future Deaths (PFD) report you have issued raising concerns about bed capacity and patient flow at the Stockport NHS Foundation Trust over the 2019/20 winter period. It is clear that the Trust and its local system partners must reflect carefully on the findings of your investigation and take the necessary action, quickly, to improve the safety and quality of urgent and emergency services in Stockport; As you will know from my response to previous PFD reports raising these concerns, regulatory action was taken by the Care Quality Commission (CQC) following an inspection at Stepping Hill Hospital in January and February 2020. The CQC's inspection looked at urgent and emergency services, among other services, and identified significant concerns similar to those identified in your investigation of Mr Cheetham's death.

The CQC found that people were not always kept safe and were at high risk of avoidable harm during periods of heavy demand on urgent and emergency care services: Emergency care was consistently unable to be provided in a timely way; and there were significant issues with the flow of patients through the emergency department and the Hospital. The report of the CQC's inspection is available on its website' . am advised that following the CQC's inspection, health system partners in Stockport formed a system improvement board, that has representation from CQC and NHS England and NHS Improvement (NHSEI); to oversee the implementation of an improvement plan to address the concerns identified. expect this work to take into account the findings of your investigation into Mr Cheetham's death and my officials have brought the concerns in your report to the attention of CQC and NHSEI: am assured that progress is being closely monitored by the Trust Board and that the CQC is also monitoring progress with a follow up inspection conducted in August 2020. Furthermore, am informed that the issues at Stockport NHS Foundation Trust have been escalated within NHSEI national govemance structures, including to the Executive Quality Group (EQG), chaired by Stephen Powis, National Medical Director; and Ruth Chief Nursing Officer; and the Joint Strategic Oversight Group with senior representation from the CQC. am advised that progress is regularly monitored: Ata national level, would Iike to explain the action we are taking to support the NHS respond to the year-on-year increase in demand on NHS services and in particular, alleviate the impact of increased activity in the winter: In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care need and expect in a timely and safe manner: For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111,as well as initiatives such as Same Emergency Care, to reduce non-elective admissions to hospital. This year; we have provided an extra E3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS's use of independent sector hospital capacity: A further E2.7billion will go directly to local NHS systems as part of their block contracts for the second half of this year: Other elements of the NHS winter plan for 2020/21 include the expansion of NHS 111 to support patients who need urgent care advice and direct them to the right service more quickly, rather than waiting in A&E? httpsIlcgCorg uklgroviderIRW https ll englandnhs uklurgent-emergency-carelnhs-11 next-steps-for-nhs-LL1L May; they Day'

NHS Trusts across England, including the Stockport NHS Foundation Trust; will receive a share of E4sOmillion additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19. Stepping Hill Hospital, Stockport is being allocated E3,611,000 of this funding to upgrade its emergency department; The NHS Long Term Plan? , published in January 2019, is supporting the reform of urgent and emergency care services to ensure that patients get the care need quickly; relieve pressure on A&E departments, and manage winter demand spikes. The NHS Long Term Plan is supported by an NHS budget increase of E33.9billion in cash terms by 2023/24. This year we made E1.3billion funding available via the NHS to support the hospital discharge process in March: As part of the E3billion funding for winter; an extra Es88million was confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital. We know that adult social care capacity can become increasingly pressured over the winter months and this can have a knock-on effect on NHS hospitals: It is important that suitable packages of care are available to ensure that patients who are medically fit to be discharged are able to return home and into their communities. This frees up hospital beds and ensures that people who really need hospital care, receive it, We also recognise that staying in hospital when patients are fit to leave can impact on wellbeing and affect people's prospects of regaining the level of health and independence they had before admission; Despite the fact that the NHS is busier than ever before, with hospital admissions rising by 18 per cent from 2009/10, the majority of patients are discharged quickly: Both the NHS and social care services have been working hard to reduce delays and free up beds. It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. NHS providers are expected to begin planning for a person's discharge at the of admission, which should include practical arrangements, care requirements and where the person is being discharged to: The hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays. The NHS Term Plan commits funding worth €4.Sbillion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge. https Ilww longtermglan nhsukl they point- Long

hope this response is helpful: am grateful to you for bringing these concerns to my attention: 2- EDWARD ARGAR MP 1377