Dear Mr Spinney

REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Andrew Tizard-Varcoe

I am writing in response to your correspondence dated 31 March 2025 regarding the Regulation 28 Notice of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the death of Andrew Tizard-Varcoe which concluded on 27 March 2025.

We have set out the matters of concern as raised in the report below and our response to them.

MATTERS OF CONCERN

1. Consideration should be given to reviewing the process of managing and treating patients with multiple health conditions, being treated across different hospital trusts, to ensure greater coordination, collaboration and optimal treatment. It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families

There are areas within the Trust that do work across more than one NHS Trust, such as vascular surgery, and they have a shared care agreement as part of a hub and spoke agreement, where SFT is the hub. This does allow access for all partners involved to certain medical records across the whole pathway, but we recognise this is harder to achieve in organisations, such as ours, where not all medical records are on the same electronic system.

Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.

Within the Trust we do have the complex care team who provide support to people with complex health and social care needs, often working in an integrated neighbourhood Trust Management Office Musgrove Park Hospital Barton House South Parkfield Drive Taunton TA1 5DA 28 May 2025 Mr P Spinney HM Senior Coroner The County of Devon, Plymouth and Torbay c/o Devon Coroners Court Sent via email to

team model. These teams aim to improve care, reduce hospital visits, and empower individuals to manage their health and live as independently as possible. They offer various services, including care planning, coordination, and support for families and carers.

2. Consideration should be given to reviewing arrangements for follow-up outpatient appointments in the ear, nose and throat departments in the Royal Devon University Healthcare NHS Foundation Trust and the Somerset NHS Foundation Trust, to ensure effective monitoring. Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.

I hope that the above information has been helpful. Can I also take this opportunity to express my condolences to Mr Tizard-Varcoe’s family for their loss.

Please do not hesitate to contact me if you require any further information.

Your sincerely

CHIEF EXECUTIVE Somerset NHS Foundation Trust

Dear Mr Spinney

I am writing further to the Regulation 28 Report issued on 31 March 2025 following the inquest touching the death of Mr Andrew Tizard-Varcoe.

Your raised three areas in which you considered action should be taken:

1. Consideration should be given to reviewing the process of managing and treating patients with multiple health conditions, being treated across different hospital trusts, to ensure greater coordination, collaboration and optimal treatment.
2. Consideration should be given to reviewing arrangements for follow-up outpatient appointments in the ear, nose and throat departments in the Royal Devon University Healthcare NHS Foundation Trust and the Somerset NHS Foundation Trust, to ensure effective monitoring.
3. Royal Devon University Healthcare NHS Foundation Trust to consider reviewing the arrangements for patient discharge in circumstances where a patient is being treated across different specialisms, to ensure that there is consultant oversight in all areas of ongoing treatment.

I will address each of these in turn.

Consideration should be given to reviewing the process of managing and treating patients with multiple health conditions, being treated across different hospital trusts, to ensure greater coordination, collaboration and optimal treatment.

Mr Tizard- Varcoe received treatment from April 2021 – May 2022 at both North Devon District Hospital and Royal Devon and Exeter Hospital which were, for most of that time, part of different hospital Trusts. However, it is worth clarifying that at the time, the ENT service was a single service across both sites although they were different hospital trusts. ENT has been a single service (based in East with clinics in Barnstaple and community locations) since 2016. The main issue was the different medical record systems that were in use at the time. The clinicians who saw Mr Tizard- Varcoe at these hospitals were from the same treating team but it is acknowledged that the medical records systems were different, and this did not provide optimal care for patients.

Royal Devon and Exeter Hospital (Wonford) Barrack Road Exeter EX2 5DW

CHIEF EXECUTIVE’S OFFICE Direct Dial:

Email:

Chief Executive Officer: Chair:

In April 2022, the two Trusts formally merged creating Royal Devon University Healthcare NHS Foundation Trust and by July 2022, both sites and all staff were using the same electronic records system (EPIC). This use of the one combined patient record has significantly improved care for patients receiving care across both sites and this has been a significant and important change since Mr Tizard-Varcoe’s death.

A significant driver for this merger was to help address some of the issues encountered by Mr Tizard- Varcoe especially in providing significantly more joined up care for patients across the two sites.

As part of the Integration Programme a detailed exercise was undertaken to identify and agree the core principles which would underpin any decisions made during the integration of teams and services. These are as follows:
• This will be a clinically-led programme of work across North and East
• There will be equity of access for our population across Northern and Eastern Devon, without diminishing the quality of care where the service functions well
• To view each specialty as a single service
• To keep as many clinical specialties at the North site as possible and develop high quality handover of care to specialist teams where this cannot be provided
• To optimise the use of technology to support remote advice and decision making to enhance and maintain the provision of clinical services across the multiple sites
• The solutions described must work for clinicians at both sites (Integration Patient Benefit, 2022 )

I am assured that since the merger of the two Trusts and the implementation of Epic in across both sites and, continuity of care and patient safety has been improved.

Many specialist healthcare services (such as ENT and vascular services used by Mr Tizard Varcoe) are now provided in increasingly more specialist centres nationally. The ENT service was specifically mentioned in the merger business case as a service that had an existing Service Level Agreement with the RDE pre-merger but would be strengthened by the levers that being one organisation and one team would bring.

At the moment, patients attending our Northern services who require vascular care are referred to Musgrove Park Hospital in Taunton and not to the RD&E in Exeter. This is a commissioning decision and so the decision of where to refer such patients sits with the commissioners and is not something I have influence over. However, we will review whether complex patients like Mr Tizard-Varcoe (who are receiving care under numerous specialities within RDUH) can be seen in Exeter for vascular issues.

It is accepted that the above changes described will not necessarily improve coordination with those patients receiving care across Somerset and Devon. However, there is a planned move across the whole of Devon itself (to include Torbay and Plymouth Hospitals) to use one electronic patient records system and this is due to go live in Torbay in April 2026 and in Plymouth in July 2026 which will again improve the coordination of care for all patients across Devon.

The introduction of nationwide records system it is outside of my remit and this should be addressed to NHS England. However, I can reassure you that there has been and there is ongoing significant change across the whole of Devon which will improve coordination, collaboration and optimal treatment of patients across the county.

Consideration should be given to reviewing arrangements for follow-up outpatient appointments in the ear, nose and throat departments in the Royal Devon University Healthcare NHS Foundation Trust and the Somerset NHS Foundation Trust, to ensure effective monitoring.

Chief Executive Officer: Chair:

At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.

These changes include monthly dashboard meetings with the bookings team and the senior operations manager of the specialty. At these meetings, the number of overdue follow ups and the capacity to see patients are reviewed so that clinical capacity can be made available and to ensure patients are seen within recommended clinical time frame.

Another one of the changes that has been implemented is that the use of the EPR system has been further developed to include a “fast pass” and “ticket scheduling system” that sends out any vacant slots to the patients suitable for booking up to 6 times daily via the MyCare (EPR) app until the slots are filled. Patients can bring pre-booked appointments forward to a closer date.

Ticket scheduling is another change due to be brought in which will be a virtual booking system on our MyCare app. This feature will send out notifications to the patients inviting them to book an appointment, the app will present all available slots to the patient for booking. All bookings are completed and confirmed via the app. Any patients without the app will still be sent standard letters inviting them to clinic. This will avoid patients having to call into the office for an appointment which will be much faster.

In terms of the ongoing validation, there is a new column on work queue (waiting lists) showing expected dates of next appointment and the percentage overdue which better reflects the urgency of a patient’s appointment to allow these to better managed. Further, there are also more staffing at the central booking office enabling more effective validation using these tools on the EPR.

Because of all these changes, we are assured that the majority of patients are being seen within the recommended clinical time frames and the tools for booking and monitoring of this are more robust. There are occasions when this does not happen due to lack of capacity in clinics and because some patients don’t respond to our invitations to contact us to book their appointment, but the service is now aware of these patients and action is taken to ensure they are seen as soon as possible. The above changes which have already taken place since Mr Tizard-Varcoe’s death, and those due to come in, assure me that significant work has been done to improve ENT outpatient follow up and that these follow ups are monitored efficiently.

Royal Devon University Healthcare NHS Foundation Trust to consider reviewing the arrangements for patient discharge in circumstances where a patient is being treated across different specialisms, to ensure that there is consultant oversight in all areas of ongoing treatment.

At the time of Mr Tizard-Varcoe’s admission in October – November 2021, he was discharged while under the care of the ENT Team. The discharge summary was written by a respiratory physician as a large proportion of Mr Tizard -Varcoe’s care was provided by the respiratory team during his admission. However, the error in not prescribing the antibiotics did not sit with that doctor and the respiratory team. The decision to stop the antibiotics was made by a junior ENT doctor misinterpreting the advice of the ENT Consultant and Microbiologists. He should have been discharged with antibiotics but these were discontinued by the ENT junior doctor.

Chief Executive Officer: Chair:

At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed to the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.

I hope the above information is helpful and addresses the concerns you have raised. Please do let me know if you have any further questions and I will be very happy to assist.