Dear Mr Arrow, Prevention of Future Deaths Notice Thank you for your report of 13 December 2024 (Case Reference ) made under the Coroners and Justice Act 2009 and the Coroner’s (Investigations) Regulations 2013, following the inquest conducted into the death of Jean Langan. The Department for Transport (DfT) are deeply saddened by the circumstances of Jean Langan’s death, and we would like to extend our condolences to her family and friends. We will learn from this tragic event and are taking action to mitigate the risk posed to members of the public, staff and flight crew at hospital helicopter landing sites (HHLSs) across the UK. Since 2020, there have been three downdraft events in the UK (excluding the Derriford Incident) investigated by the Air Accident Investigation Branch (AAIB). These all involved air ambulances operating on scene away from HHLSs, with two resulting in injuries to members of the public. The DfT is aware of the risks posed by rotary aircraft and will continue to endeavour to mitigate these as far as possible. Hospitals are responsible for the safety of HHLSs located on their grounds. The DfT is responsible for overseeing the safety only of licenced helipads. Currently, all HHLSs are unlicenced. This means they do not have to comply with CAA’s CAP 1264 guidance for hospital helicopter landing areas. I M Arrow County Hall Topsham Hall Exeter Devon EX2 4QD From the Secretary of State

Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR Tel: E-Mail:

However, we are determined to play our part in reducing the risk at these sites as far as possible. We are also acting on the AAIB’s recommendation to strengthen oversight of HHLSs. In conjunction with the CAA and industry, the DfT is currently considering whether to legislate to ensure safety at all HHLSs. This would be a long-term (2-4 year) project requiring secondary legislation.

The DfT has carefully considered your report and its recommendation to develop a database of HHLSs. It is the responsibility of hospitals to procure and maintain any database. We will assist DHSC, hospitals and the NHS by developing options for a database that meet your and the AAIB’s recommendations. We have already started this work. DfT is the co-chair of the Onshore Leadership Group (OnSLG), a forum of rotary operators including air ambulances, Bristow Helicopters and utility operators. This has helped us to investigate how a dynamic and comprehensive database of all HHLSs can be established. We have also spoken to the supplier of the offshore helipad database, and the existing supplier of mapping software to much of the air ambulance and SAR communities. The DfT also participates in several other industry-wide forums such as the NHS HHLS Group, the New Hospital Programme HHLS Forum and the Air Ambulance Operation Director’s Group.

We understand that the Department of Health and Social Care (DHSC) will respond on your recommendation to ensure each HHLS has an accountable manager. We also understand that DHSC will work with NHS England to implement the demands in Bristow’s letter of 6th of December 2024. A named accountable manager is essential to the establishment and maintenance of an HHLS database, and the DHSC is working with national health authorities to ensure that each HHLS has a named and competent accountable manager.

Dear Mr Arrow

Thank you for the Regulation 28 report of 13 December 2024 sent to the Secretary of State for Health and Social Care about the death of Ms Jean Langan. I am replying as the Minister of State for Health with responsibility for the NHS Estate. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Langan’s death, and I offer my sincere condolences to their 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. The report raises concerns over:
• A need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
• A need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters.
• More particularly to address the points below, as set out by Hogan Lovells who are the representative for the Air Service Operator Bristows in the letter of the 6 of December 2024:

1) Details of the responsible person/accountable manager for each NHS England hospital with a Hospital Helicopter landing site (HHLS).
2) Copies of all Standard Operating Procedures as they exist now insofar as they relate to helicopter operations.

3) An update on the status of their Helicopter Operations Manual (HOM) with target date for completion.
4) Confirmation that NHS Trusts have engaged with the Civil Aviation Authority (CAA) to ensure all relevant personnel have attended or are planned to attend the CAP 1264 course. A target date for completion should be provided.

In preparing this response, my officials have made enquiries with NHS England and the Department for Transport to ensure we adequately address your concerns. We will learn from this tragic event and will take action to help mitigate the risk posed to members of the public, staff, and flight crew at hospital helicopter landing sites (HHLSs) across the UK. DHSC has a limited role in enforcing HHLS safety. DHSC has carefully considered your report and its recommendation to develop a database of HHLSs. We are engaging with NHS England and the Department of Transport to determine how best to implement this recommendation and ensure a database is fit for purpose. Turning to your recommendation to ensure each HHLS has an accountable manager, we agree a named accountable manager is essential for the safe running of HHLS and NHS England now have this information for all Trusts. As of the 31 January 2025 a named accountable manager has been identified and supplied, this is essential to the establishment and maintenance of an HHLS database. DHSC has worked with NHS England to implement the requests in the letter (noted above) from Bristow’s, the Helipad operator for Search and Rescue Service (SARS) helicopters dated the 6th of December 2024 to the coroner. Work is currently ongoing to deliver this. HHLS are not licensed landing sites like aerodromes or airports. Instead, the Civil Aviation Authority (CAA) provides non-statutory guidance to the NHS on HHLSs, through the Civil Aviation Publication (CAP) 1264 “Standards for helicopter landing areas at hospitals”. This guidance covers issues such as operation and management, covering approach and departure paths, obstacle clearance, lighting, signage, and communication protocols. NHS England expects NHS trusts to follow the CAP1264 guidance. Through work they are undertaking to address the points set out above (and in Bristow’s letter of 6 December) NHS England will ensure that HHLS meet the CAP 1264 requirements, as appropriate.

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

Dear Mr Siddique, Thank you for your Prevention of Future Deaths report of 23 October 2025 raising the concerns you have regarding following two points within the Sandwell and West Birmingham NHS Trust policies:

 There was confusion and lack of understanding by nursing staff in relation to when the EMRT should be called in an emergency particularly when a DNAR was place.  There was a lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place.

We have taken appropriate steps to address your concerns and ensure that staff have the clarity required to support decision making when required in the emergency situation. We have undertaken the actions listed below:

 Amended the Emergency Medical Response Team (EMRT) policy to clarify that EMRT calls are appropriate when there is an immediate/recoverable/un-expected event such as choking or airway compromise – even when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is in place  This policy has been uploaded onto the policies platform to ensure availability to all staff who require it – staff will be notified of a new version being available  The policy update has been communicated to Senior Leaders, Governance and Safety leads and team leader/ward management within the Clinical Directorates via weekly clinical directorate governance meetings and at the monthly Patient Safety Oversight Meeting to ensure effective dissemination of the updates  It is planned to highlight the updated policy to Senior Leaders within the Risk and Assurance Group scheduled for 15th December 2025

 A safety alert has been published across the whole Trust, to ensure that staff are aware of the need to call the EMRT when an immediate/recoverable/un-expected event such as choking or airway compromise – even when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is in place. Assurance has been received from the clinical directorate representatives at the Patient Safety Oversight Meeting that they are aware of the safety alert and have disseminated in their areas  A communication bulletin has been released to highlight the policy update to all staff  An exercise to align the wording within the EMRT policy and the Treatment Escalation Plan policy has been undertaken to provide consistency in language across both policies to reduce confusion for staff and reinforce the required message to staff

To address the concerns related to the SALT assessment requirements, we have undertaken the following:

 Commenced a cascade training programme to have swallowing safety cascade trainers for each ward area, who are responsible for training their ward teams. To date 44 nurses have been trained in this role.  As a priority ALL emergency admissions routes now have swallowing safety cascade trainers in place.  80% of nursing and HCA staff in our ED department have received AT LEAST one form of direct training in swallowing awareness  We deliver training on the new junior doctor induction programme bi-annually (each intake)  Referrals to SALT continue to be available  Dysphagia guideline has been re-circulated to all clinical directorates  Dysphagia guideline is available on the policy platform to ensure availability when required by all staff  Online training available to all staff for swallowing assessment  Swallowing assessment/Nutritional assessment is the topic of a planned safety bulletin to be circulated in December

I trust this information will provide you with reassurance regarding the concerns raised in your report, however, if I can assist with anything further, please do not hesitate to contact me.