Dear Mr Hodson, Re: Regulation 28 Report to Prevent Future Deaths – Peter Michael Anzani who died on 23 November 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 May 2025 concerning the death of Peter Michael Anzani on 23 November 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Peter’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about Peter’s care have been listened to and reflected upon.

Your Report raised the concern that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) had repeatedly requested additional funds for workforce development and expansion but was not being adequately supported financially by NHS England, and that two Workplace Funding Reviews were turned down by NHS England. Peter was a patient of the Midlands Centre for Spinal Injuries (MCSI). The Spinal Cord Injury (SCI) Service at RJAH is a specialised commissioned service that provides care in line with the national service specification 170119S (Spinal Cord Injury Services (Adult & Children)). Specialised commissioned services support people with a range of rare and complex medical conditions and often include treatments for such conditions. Specialised commissioned services are not directly commissioned or funded by NHS Trusts. Historically, NHS England has directly commissioned all specialised services, but Integrated Care Boards (ICBs) are now increasingly taking a larger role in commissioning some specialised services, as part of an agreed delegation of responsibilities to ICBs. You can find out more information about specialised services here: NHS commissioning » Specialised services The SCI service specification outlines the requirements for initial inpatient management of traumatic and non-traumatic SCI patients and the ongoing ‘lifelong’ management of patients with SCI. Following inpatient discharge from a SCI unit, patients are reviewed by outreach practitioners and in outpatient clinics. Care for the consequences of SCI is life-long with regular clinic or telephone review appointments (6 weeks, 6 months, and 1, 2 and 3 years then at least every 3 years or more often depending on the clinical indications). Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25 June 2025

To aid my response, my Regulation 28 Leads for the Midlands region have reviewed Peter’s care. As part of his lifelong care, Peter was overseen by an outpatient model of care as per the national SCI service specification. To support and provide mitigation to outpatient waiting lists for follow-up clinics, a nurse-led triage process is undertaken which involves contacting patients to clinically risk assess and prioritise patients that need to be seen. In line with the RJAH Harms Policy, Peter was contacted by a senior nurse as part of the prospective harms process on 14 August 2024 and, following this, some concerns were raised triggering an urgent review. An appointment was then expedited and he was seen in clinic on 20 August 2024. The agreed action plan put in place included:
• pressure ulcer management advice
• GP request to monitor and manage chest issues
• a review in 18 months’ time by an MCSI practitioner, or earlier if there was any need. This was three months prior to his admission to Heartlands Hospital on 22 November
2024. NHS England’s Specialised Commissioning funds RJAH’s SCI service as part of a block funded commissioning system to cover the complete costs for the service, including inpatient and outpatient activity with inflationary finance being applied to all NHS England contracts annually since 2020. As a Foundation Trust, RJAH take organisational decisions on individual service spends, including workforce, to deliver services as identified in the national service specification. In June 2024, a Trust internal workforce review was shared for information with NHS England and we understand this is being updated at this current time. No formal requests for funding have been received through the contract review meeting process between RJAH and NHS England, to support the findings of the RJAH internal review. NHS England was not given Interested Party status or asked to provide any witness evidence during the inquest into Peter’s death. The Coroner’s findings have resulted in an internal NHS England review and we have not identified any specific formal workforce funding requests that have been rejected by NHS England for the SCI service at RJAH with regard to outpatient services. During 2023/24, workforce development funds of £171,077.73 were allocated to Shropshire Telford and Wrekin (STW) ICB, which includes RJAH as one of four Trusts operating in this system. The funding was used for system wide initiatives. While there was no specific workforce development funding allocation in 2024/25, RJAH have not been refused any of the Clinical Expansion / Multi-professional Education and Training Plan Considerations posts that they requested. In 2024/25, some Advanced Practitioner MSC training places were allocated to them, which they did not utilise. 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

Peter, 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 Mr Hodson Re: Regulation 28 Report to Prevent Future Death - Peter Anzani Inquest Thank you for your Report to Prevent Future Deaths (hereafter “PFD report”) dated 1 May 2025 concerning the death of Peter Anzani on 24 November 2024. In advance of responding to the specific concerns raised in your PFD report, I would like to express my deep condolences to Peter’s family and loved ones. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (hereafter “the Trust”) is keen to assure the family, and the Coroner, that the concerns raised about Peter’s care have been listened to and reflected upon. I am advised that the Trust was not initially recognised as an Interested Person (IP) to this inquest nor provided with a copy of the statements and documentation from other IPs ahead of the inquest. I understand that the Trust was recognised as an IP following a verbal application made by the Trust’s legal representative during the inquest hearing. As a Trust, we fully recognise the importance of addressing the concerns raised by your PFD report to prevent similar instances in future. I have set out the concerns outlined in your PFD report below and the relevant work the Trust has undertaken.
1. I considered evidence from a who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded of confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I

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1006127061.1 have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…”
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of learning. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. Immediate actions Following receipt of the PFD report, the Trust took immediate action to address the issues identified, specifically relating to timely and accurate recording of patient observations. Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication. Also, a re-audit was completed on 21 June 2025 in relation to 20 patient who attended the clinic between 16 – 19 June 2025. The results show that a full set of clinical observations was recorded for 100% of patients, including those undergoing procedures. A copy of the audit has been provided in the Trust’s PFD response bundle. Digital record keeping system The Trust has undertaken a review of how our current systems and processes to support accurate and timely clinical documentation. One of the key tools supporting this work is implementation of our new electronic patient record system called Apollo, which is used Trust wide to facilitate consistent, legible and auditable documentation of patients’ clinical notes. The Outpatient Observation Form now includes all baseline observations, and this essentially follows the process used in the Trust’s Main Outpatient Department. A paper format will be utilised during any period of digital downtime, when access to the digital system is limited, or not available. In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments. Standard Operating Procedure A new Standard Operating Procedure (SOP) has been developed and is in the process of being implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The SOP includes a flowchart to ensure ease of understanding and practical application across all relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.

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1006127061.1 The SOP further specifically requires completion of pre- and post-procedure observations in higher-risk outpatient procedures, including Baclofen, Fertility, Botox and Suprapubic Catheter (SPC) clinics. We consider these actions are essential to ensure patient stability before and after interventions that may involve medication administration, sedation, or procedural risk. Quality Accreditation Programme The Trust has adopted a local Quality Accreditation Programme (QAP), and we are using this as a structured and sustainable mechanism to drive improvements across all clinical areas. As part of the QAP, all wards, units and departments at the Trust will aim to achieve the highest level of quality accreditation to improve efficiency, productivity, patient outcomes and to enhance patient and staff experience. This underpins the goals of the Trust’s Nursing and Allied Health Professional Strategy, the Trust’s Quality Strategy and wraps a framework around demonstrating regulatory compliance and best practice. The objective and focus of this work are to align the QAP to CQC’s key principles of Safe, Effective, Caring, Responsive and Well Led. I have provided within our PFD response bundle the QAP audit in relation to documentation and record keeping. Where compliance was found to be less than 100%, the Trust has recommended steps to ensure increased compliance. Moreover, the quality accreditation process has helped guide Trust’s quality improvement priorities for the year. Some of the core objectives of the Trust’s quality improvement priorities include improvement of documentation and record keeping related to falls risk assessments and management plans. The Trust has also prioritised measures to improve the use of fluid balance charts across the Trust. The measures agreed to achieve these objectives are focused on improved compliance with completion of risk assessments, management plans and fluid balance charts (via tenable audits). A copy of the Trust’s Quality Priorities has been provided in the PFD bundle. NEWS2 compliance audit To evaluate adherence to national standards for the National Early Warning Score (NEWS2) system, a compliance audit was carried out by the Trust’s Patient Deterioration & Resuscitation Committee in January 2025. The objective of this audit was to review whether the Careflow Vitals (formerly VitalPAC) e- observation NEWS2 track, and trigger system supports prompt and appropriate escalation for a physical review by an appropriate competent clinician. The review involved a retrospective audit of NEWS2 clinical observations and escalation, which included a review of 565 observation datasets from 112 patients. The audit report highlighted the National Institute of Clinical Excellence’s (NICE) clinical guideline entitled ‘Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital’ (NICE clinical guideline 50). As outlined in the Trust’s audit report, one of the key recommendations in the NICE guideline is that as a minimum physiological observation such as heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation and temperature should be recorded at the initial assessment.

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1006127061.1 The audit report has made appropriate recommendations and actions for better outcomes, which has been provided in our PFD response bundle. I confirm that a repeat audit has been scheduled for April 2026. Deteriorating patient compliance audit The Trust also undertook a compliance audit in January 2025 pertaining to deteriorating patients, which involved a review of monitoring and escalation of patient care. This was a retrospective audit of 113 2222 medical emergency calls and cardiac arrests. This audit similarly refers to the NICE guideline referred to above and recommendation relating to recording of physiological observations. The audit makes mention of a report from the National Patient Safety Agency (NPSA 2007), which evidenced failure to recognise and act upon deterioration in 15% of serious incidents resulting in death reported on the national reporting and learning system (NRLS). The sub-themes identified were a failure to measure basic observations of vital signs, a lack of recognition of the importance of worsening vital signs and delay in responding to deteriorating vital signs. Accordingly, the Trust’s audit (amongst other recommendations) has emphasised learning around the global assessment of patients “including review of the patient’s baseline physiological trends and not solely upon the NEWS2 score”. I confirm that a repeat audit has been scheduled for February 2026. I hope the above offers you reassurance of the Trust’s ongoing commitment and work being undertaken, specifically relating to the issues raised in your PFD report. The following documents are included in the PFD disclosure bundle.
• The NEWS2 compliance audit (appendix 1)
• Deteriorating patient compliance audit (appendix 2)
• The latest MCSI observational audit of 21 June 2025 (appendix 3)
• Quality Priorities 2025-26 (appendix 4)
• Quality Accreditation Programme – Documentation and Record Keeping (appendix 5) Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.