Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Kasey Beech who died on 13 October 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 August 2024 concerning the death of Kasey Beech on 13 October 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Kasey’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Kasey’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Kasey’s family or friends. I realise that responses to Coroner’s Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

The matters of concern as presented in your Report include the use of the STREAMing model / guidance to assess and exclude a cardiac cause of chest pain in new non- injury ambulatory patients. In particular, you raised that the prioritisation of current cardiac sounding chest pain and the streaming to the Medway on Call Care (MedOCC) or an equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration, creating a risk of future deaths in both cardiac and non- cardiac patients.

NHS England have engaged with colleagues at Medway Maritime Hospital to understand how the STREAMing model upon which their Urgent Treatment Centre (UTC) operates and I can confirm that NHS England does not endorse a particular STREAMing model nationally. The training and experience of the initial assessor at an UTC is critical to patient safety and the Royal College of Nursing (RCN) and the Faculty of Emergency Nursing (FEN) have specific training and competencies for clinical staff working in initial assessment roles. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

19 December 2024

Models of initial assessment currently in use prioritise a patient with chest pain as an acuity 2 patient who should be seen urgently, with a general aim (based on international consensus) that this should be within 10 minutes. NHS England is currently developing a new initial assessment model in collaboration with the Royal College of Emergency Medicine (RCEM), the RCN, the FEN, the Emergency Nurse Consultant Group, and lay (patient) representation. This new model has been successfully introduced in more than 20 sites across England and is specifically focused on improving patient safety. This new model has been successful in bringing down the time to initial assessment to below 15 minutes in sites where it has been implemented. The Emergency Care Data Set, introduced in 2017, discouraged the concepts of 'cardiac chest pain' and 'non-cardiac chest pain' for the reasons identified in your Report. Instead, all chest pain was coded solely as 'chest pain'. In response to your specific concerns relating to the care of Kasey, I have consulted with NHS England’s National Clinical Director for Heart Disease. They advise that it is recognised that pain can often fluctuate over time but that the lack of ongoing pain in someone with other features suggesting a low risk profile is clinically reassuring, and the streaming / direction of Kasey to the MedOCC was appropriate in the circumstances.

As noted in your Report, pain can also be masked by analgesia, especially if intravenous or intramuscular opiates have been administered prior to assessment. This is a key reason why other features such as the general condition of the patient and any breathlessness must be assessed. These assessments are included in the STREAMing pathway.

Following their review, I am advised by the National Clinical Director that the STREAMing pathway in use by Medway Maritime Hospital does not have an undue prioritisation of chest pain (particularly cardiac-sounding chest pain). As indicated above, the general condition of the patient, any signs of breathlessness, their ability to talk in sentences and their ability to walk unaided are all assessed. In this tragic case, the initial assessments all pointed towards a low-risk situation for which direction to the MedOCC was appropriate. A low risk initial assessment does not completely rule out the possibility of future deterioration but usually indicates the lack of a need for immediate treatment.

In this case, Kasey deteriorated rapidly after leaving the MedOCC. It does not appear that modification of the STREAMing pathway would have been likely to have predicted that or altered the outcome of the initial assessment.

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

Kasey, 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 Mooyart, Further to your prevention of Future Deaths Notice following the conclusion of your inquest (8th November 2023) into the death of Kasey Beech who died on 13th October 2021, we would like to extend our sympathy and condolences to the family and friends of Ms Beech. We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than Emergency Department (ED); from the described circumstances of Ms Beech’s death, it is not clear whether the UTC was effectively ‘gatekeeping’ access to an emergency department or not. Regarding the Simple Triage Rapid Emergency Assessment Method ‘STREAMing Model’a, we have not been able to find any specific details regarding what appears to be an initial assessment tool, and we do not believe that this is an assessment tool that is routinely used in emergency departments. As a consequence, we are not able to provide any specific response to your concerns regarding the apparent prioritisation of cardiac sounding chest pain over other potentially life-threatening conditions.

The Royal College of Emergency Medicine (RCEM) has issued the following guidance regarding the initial assessment (triage) of patients [1]

• The front door of the Emergency Department should be managed by the ED and fall within its quality improvement and governance systems.
• Gatekeeping to the ED by non-Emergency Department services is not supported.
• Emergency Departments use simple or complex streaming [2], as part of their initial assessment processes. Both processes should be resourced to meet variation in demand and be delivered by trained clinical staff.

The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved

a Streaming is the process of allocating patients to different physical areas / services, pathways or processes, to improve efficiency and effectiveness. The main objective of streaming is to ensure that the patient is directed to the correct location / service and to the correct person to manage their clinical needs. Streaming should always be performed by a trained clinician.

an evidence-based review of the effectiveness of current triage systems as well as helping to design a new initial assessment process for implementation in all emergency departments throughout England [3].

Dear Mr Mooyaart

Re: Regulation 28 Prevention of Future Deaths Report (of Kasey Beech)

I write in response to your regulation 28 report dated 29 August 2024 regarding the very sad death of Kasey Beech. I would like to express my sincere condolences to Kasey’s family.

The patient safety leads at NICE have carefully considered the content of your report and understand that your request relates to the use of the clinical streaming model and the organisation of acute care within the NHS.

Given that the matters of concern relate to the prioritisation system (STREAMing) which was produced by NHS England, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and note that you have also sent your report to them for response.

Although not directly mentioned in your report, you may be interested to learn that we are updating our guideline on Asthma: diagnosis, monitoring and chronic asthma management and this update is expected to publish on the 27 November.

I am sorry that we cannot comment further on the matters raised, and would like to reiterate my condolences to Kasey’s family.