Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Tamara Davis who died on 13 December 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 October 2024 concerning the death of Tamara Davis on 13 December 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Tamara’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Tamara’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 Tamara’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. Your Report raises the concern that patients are being treated in the corridors of Emergency Departments when the departments have reached their full capacity and space in clinical areas is not available. This is considered by the Coroner to be a national issue and does not just apply to the Royal Sussex County Hospital in Brighton, where Tamara passed away.

My response to the Coroner has been informed by colleagues in the Urgent and Emergency Care Team at NHS England and the South East Regional Clinical Quality Improvement Team.

The delivery of care in temporary escalation spaces (TES) in departments experiencing patient crowding (including beds and chairs) is not acceptable and should not be considered as standard across the NHS. TES refers to care given in any unplanned settings (such as corridors) and recently NHS England have published a set of principles for supporting improved quality of care should patient demand outstrip capacity - NHS England » Principles for providing safe and good quality care in temporary escalation spaces (16 September 2024). These principles have been developed to support point-of-care staff to provide the safest, most effective and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 December 2024

highest quality care possible when TES care has been deemed necessary, and the principles should be applied alongside any local standard operating procedures and arrangements governing flow pathways and safe staffing. In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge. My Regional colleagues in the South East Clinical Quality Improvement team have recently visited the Emergency Departments at both University Hospitals Sussex in Worthing and Royal Sussex County Hospital as part of a programme of joint Nursing and Integrated Care Board (ICB) visits to NHS Trusts, led by their Deputy Director. The programme of visits aims to understand how and why patients are selected to reside in non-designated areas, how they are observed for deterioration, and how dignified care can be provided. These focused reviews of non-designated care practices in the Emergency Department have included engaging with staff, patients and relatives to test safety measures in place and provide detailed feedback for the organisations on areas for improvement. NHS England has also reviewed the response to the Coroner from University Hospitals Sussex NHS Foundation Trust dated 10 December 2024. We note and welcome the various workstreams in place to improve flow through the hospital, reduce hospital attendance and optimise discharge pathways. 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 Tamara, 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.

Dear Ms Andrews

Inquest into the death of Tamara Davis

Thank you for your letter of 15 October 2024, enclosing your formal report under Regulation 28 to Prevent Future Deaths, to NHS England & NHS Improvement, Department of Health and Social Care, and the Trust.

First, my sincere condolences to Tamara’s family.

Thank you for confirming that the period in which Tamara was in the Emergency Department (ED) corridor did not cause or contribute to Tamara’s death. However, I understand that you are concerned that caring for patients in the ED corridor may create a risk of future deaths.

Your Regulation 28 report has been reviewed by both the Executive team and the Medicine Division, including the Chief of Service and the Divisional Director of Nursing.

As you know from the inquest, the Medicine Divisional Leadership team are working alongside the Hospital Directors and Executive team on several separate but linked workstreams, all with the overarching aim to eradicate the use of the ED corridor for patients.

The Medicine Divisional Improvement Board has been developed to oversee and implement a number of improvement actions to enable this to be achieved. The focus is also to improve the safety, quality of care, and overall outcomes and experience for patients presenting to the ED. The Medicine Division have employed an Operational Flow Improvement Manager who is leading the Hospital Alternative Oversight Programme. The aim of this work is to reduce admissions, optimise flow through the hospital, and smooth discharge pathways and processes. A number of the initiatives already in progress are as follows:
• Unscheduled Care Navigation Hub
• Frailty Care Home Outreach & Red Bag Launch
• Frailty High-Weald Lewes & Havens Outreach
• Integrated Front Door Therapies Team RSCH (Royal Sussex County Hospital)

• Virtual Health, both General Virtual Ward and Respiratory Home Monitoring Services
• Frailty & Respiratory SDEC (Same Day Emergency Care) Optimisation
• Interprofessional Standards
• UTC (Urgent Treatment Centre) Optimisation
• Early Discharge Planning
• Deconditioning Prevention
• Tiered Acuity Model These initiatives are in collaboration with colleagues from the ICB (Integrated Care Board), Sussex Community NHS Foundation Trust (SCFT), South East Coast Ambulance Service (SECAmb) and Brighton & Hove City Council (BHCC). Unscheduled Care Navigation Hub In the Southeast, only 2.1% of call outs are conveyed somewhere other than ED. There is underutilisation of alternative pathways to admission, with 53.9% of incidents conveyed to ED. This model seeks to enhance the hear & treat and see & treat performance of SECAmb and reduce attendance to our hospitals where appropriate, and act as pre-cursor to NHS England’s Single Point of Access (SPOA) model. Continuous Flow Model - Reducing overcrowding in the Emergency Department

Continuous Flow will improve the early movement of patients from the Acute Floor. This will improve the quality of care for patients who are being treated in non-clinical spaces in the ED. In addition, it will reduce the time patients are waiting in the ED, in particular it will reduce patients waiting over 12 hours for admission to a ward.

The continuous flow model commenced on 11 June 2024 and provides guaranteed transfer of patients from the Acute Assessment Unit (AAU) to the Specialty Medicine and Frailty wards at set times planned in advance. This is currently being implemented across the Trust.

Surgical Assessment Unit (SAU) The SAU opened in October 2024 and is being expanded in line with nursing recruitment. This will increase the hospital’s bed stock by 12 patient trolley beds and 12 patient chairs. It is expected to manage most surgical patient presentations to the ED and receive ambulances directly. The SAU represents the first phase of our Acute Floor Reconfiguration which is a £48 million capital improvement programme that will improve patient and staff experience at the RSCH significantly. I hope this letter provides you and Tamara’s family with assurance that we are committed to making significant improvements to patient flow and the quality and safety in the Emergency Department. Once again, my sincere condolences to Tamara’s family.

Dear Ms Andrews,

Thank you for the Regulation 28 report of 24 October 2024 sent to the Department of Health and Social Care about the death of Ms Davis. I am replying as the Minister with responsibility for urgent and emergency care.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Davis’ death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

In preparing this response, my officials have made enquiries with NHS England to ensure your concerns are adequately addressed.

The report raises concerns over emergency department capacity, poor patient flow and the use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand that your report and matters of concerns have also been sent to NHS England, and they are best placed to respond with the specific actions being taken locally to improve urgent and emergency care performance at RSCH.

At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This report was published on 12 September 2024 and the investigation’s findings are feeding into the government’s work to develop a 10-year plan to radically reform the NHS and build a health service that is fit for the future.

The plan's reforms will support a reduction in the demand pressures on the health service through three shifts to ensure the health service can tackle the problems of today and tomorrow. These are:
• shifting care from hospitals to the community,
• from analogue to digital, and
• sickness to prevention.

In the short-term, the NHS is taking a range of action this year to improve urgent and emergency care performance, including maintaining increases in acute hospital bed capacity and greater ambulance hours on the road. There is also a focus on increasing the productivity of acute and non-acute services across bedded and non-bedded capacity and directing patients to more appropriate services in the community where these can better meet their needs.

I share your concerns regarding the use of Temporary Escalation Spaces (TES), also known as corridor care, at RSCH. NHS England highlighted key expectations regarding patient safety and overcrowding management in emergency departments in its winter operating assumptions letter, published on 16 September 2024: https://www.england.nhs.uk/long- read/winter-and-h2-priorities/. The letter reminds Integrated Care Boards and provider Chief Executives to prioritise patient safety and experience.

The guidance urges NHS trusts to ensure that care outside standard cubicles or ward environments is not normalised and is employed only during periods of elevated pressure. Furthermore, TES use should be escalated to an appropriate executive member and at the system level, with the aim of minimising its duration. These recommendations align with the recently issued guidance on TES, which can be found via https://www.england.nhs.uk/long- read/principles-for-providing-safe-and-good-quality-care-in-temporary-escalation-spaces/

I agree with your concerns that the delivery of care in TES is not acceptable and should not be considered as standard practice. All patients should be able to access the highest possible levels of patient experience, care and safety during their treatment. I understand that NHS England will address what RSCH is doing to mitigate use of TES in their reply to you.

I hope this response is helpful. Thank you for bringing these concerns to my attention.