Dear HM Coroner,

Thank you for your letter dated 16th June 2025 following the inquest of Mrs Norma Faye Campbell detailing concerns arising from the evidence presented and inviting the Trust to consider the implementation of changes to reduce the risk of future harm or death.

The Prevention of Future Death report has been reviewed at Whipps Cross Divisional and Hospital Boards to agree actions that will have an impact across the Barts Health group. The PFD and response will be shared at Trust Safety Committee, with National Health Service England (NHSE), the Care Quality Commission (CQC) and the North East London Integrated Care Board.

Your concerns

1. The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity. The inquest heard that overcrowding in A&E is a national concern.

2. The inquest heard that it is not uncommon to find patients in corridors when they need to be monitored. On the 13 January 2024 there were more than 25 patients in the corridors. They were not receiving an appropriate level of care.

3. There are often insufficient numbers of resuscitation beds. Patients who require a resuscitation area level of care are often directed to the majors area of A&E. The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients. In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care. Trust Headquarters Executive Offices Ground Floor

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4. There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.

5. The Critical Care Outreach Team (CCOT) do not currently attend A&E for deteriorating patients. The overcrowding and lack of resourcing in A&E highlights the need for the CCOT to provide support to A&E patients as well as patients on the ward.

Our response

The Trust deeply regret the concerns raised by HM Coroner and the impact the inquest findings will have had on the patient’s family. As part of the ongoing review of the Urgent and Emergency Care pathway at Whipps Cross Hospital, a weekly committee chaired by , Chief Executive at Whipps Cross Hospital commenced in February 2025 to look at the issues in the Emergency Department and our inpatient wards. This committee addresses the issues around overcrowding, the reconfiguration of the department and how the hospital will tackle “exit block” from the Emergency Department which are referenced by the concerns you have raised. Whilst this committee looks at the overall issues (with quality improvement workstreams looking at different areas) the Trust also acknowledges the specific concerns that we have addressed below. Inadequate staffing. In May 2024, the Hospital Executive Board at Whipps Cross Hospital approved the increase in whole time equivalent (WTE) medical staff from 43 WTE to 63 WTE. This was an increase in
1.1 WTE consultants, 10 WTE Tier A (registrar) grade residents and 5 additional Paediatric Emergency residents (4 at registrar grade and 1 at senior house officer grade). In addition, locum shifts equivalent to 5 WTE were also approved as part of the staffing to ensure that the department was appropriately always staffed. Recruitment has been ongoing since June 2024 and for August 2025, the agreed establishment will be fully recruited for resident doctors with successful interviews for the consultant grades on 17th July 2025. This brought Whipps Cross into line with the other Emergency Departments within Barts Health for medical staffing. For nursing staff, the Hospital Executive Board has approved an increase in 10.5 WTE nursing staff in line with the Safer Nursing Care Tool review of staffing and is currently in the process of recruiting to these posts. Both the medical and nursing staffing remain under review by the Hospital and Trust to ensure that these increases in staffing meet the needs for the patients that we care for in the Emergency Department (this includes a further staffing review of the consultant tier which should help align our staffing numbers with similar hospitals of acuity). Overcrowding / Corridor Care The Trust acknowledges that the Emergency Department does get overcrowded and at present some patients are cared for in a corridor, particularly in the “Emergency Assessment” area

where patients arriving by ambulance are reviewed when they arrive at the Emergency Department. This is reflected by the risk assessment by the Trust rating the risk of overcrowding in the Emergency Department at 20 (high risk). Where we do have days that there is overcrowding within the Emergency Department, additional nurses are redeployed to provide “fundamentals of care” and care for the patients waiting to be admitted to the hospital. In winter 2024/2025 an additional 17 bedded “temporary escalation space” was opened with dedicated nursing and medical staff next to the Emergency Department to care for patients who required admission to hospital and had already commenced treatment to free up space within the Emergency Department for patients who were requiring assessment. The Trust has committed to reconfiguring the Emergency Department at Whipps Cross Hospital. Work to do this has commenced and is due to be fully completed in March 2026. This will reconfigure the current Emergency Assessment area from 4 cubicles and some corridor space to a dedicated 14 trolley assessment area (this work is due to be completed by January 2026) and remove the current corridor space. There is also ongoing work across the hospital to reduce length of stay on the wards and prevent “exit block” from the Emergency Department. This includes a Quality Improvement programme around the use of electronic whiteboards, a dedicated workstream about discharge and a regular systems oversight meeting that looks at how health and social care organisations across Waltham Forest and Redbridge can work together to reduce delays in discharge. Looking at the Summary Acute Medicine Indicator Table (SAMIT) data for April 2025 compared to April 2024 the average length of stay in the hospital has dropped from 13.4 days to 10.9 days and we are committed to work to continue to reduce this and thus reduce overcrowding in the Emergency Department. Insufficient Numbers of Resuscitation Beds There is currently a mismatch between the number of resuscitation beds and the demand placed on them at peak times in the Emergency Department. Although we have six resuscitation cubicles, which is close to what would be expected for our population, operational realities— such as surges in ambulance arrivals and deterioration of walk-in patients—often exceed this capacity. A major contributing factor is exit block: patients who are clinically ready to be stepped down cannot be moved due to lack of downstream bed availability. This leads to unnecessary occupancy of resuscitation beds and reduces capacity for new critically ill arrivals. The works that are ongoing to help alleviate this pressure have already been mentioned above. We have planned infrastructural improvements, including a new centrally located resuscitation area near assessment zones, which is expected to enhance flow. Additionally, enforcing internal professional standards, such as mandatory consultant-to- consultant handovers, will support faster decision-making and reduce unnecessary delays in the resus area is something that the senior leadership team within the hospital is actively

promoting. Furthermore, having the increased staffing as mentioned above will also help to address decision making and facilitate more timely treatment and decision for safer disposition to other areas of the hospital. These changes are aimed at aligning resuscitation bed capacity more closely with real-time demand, improving both patient safety and departmental efficiency. No Electronic Observation System within the Emergency Department In 2024 the Trust upgraded the electronic patient record in the Emergency Department to the “Launchpoint” system provided by Oracle and purchased in May 2024 an additional 49 observations machines that directly relay clinical observations to the electronic patient record. The observations and Early Warning Scores (EWS) are then displayed on the overview panel for each clinical area within the department (and all patients can also be viewed within the department if that option is selected). The nurse in charge and senior doctor for each clinical area now have an overview of each patient within the area they have clinical responsibility for during their shift. An example of the view is shown below.

The Critical Care Outreach Team (CCOT) do not attend the Emergency Department. We would like to acknowledge and address the concern raised about the absence of a formal CCOT presence in the Emergency Department. CCOT do not currently have the skill set or resource to review acutely unwell and undifferentiated patients within the emergency department. An extended period of training would be required which will need to be determined by local service needs and referenced to outreach services that have successfully implemented this. However, we recognise the importance of timely critical care input and have alternative arrangements to ensure support is available when needed. The current pathway is that the critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care unit, is available to attend the ED, this registrar has access to a consultant intensivist at any

time of the day. While this arrangement does not replace a full CCOT presence, it ensures responsive critical care support to the ED team on request. Whipps Cross Hospital teams are committed to preventing avoidable harm to patients and would like to thank the Campbell family and HM Coroner for highlighting a gap in governance processes. We hope that this response provides assurance around the actions that will be completed and monitored to effect improvement in response to this PFD. If you have any queries, please do not hesitate to contact me.