Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – James Neil Cockburn who died on 26 May 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 July 2024 concerning the death of James Neil Cockburn on 26 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to James’ family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about James’ care have been listened to and reflected upon.

Your Report raises concerns over national delays in patients waiting to see cardiologists due to demands on the service, and for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably qualified professionals. NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however NHS Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with CQC Regulation 18, which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements. In February 2022, NHS England published the Delivery plan for tackling the COVID- 19 backlog of elective care which sets out that the NHS is working to recover elective care over a three-year period. The plan includes the ambition to bring down waiting times for elective care, as well as improving diagnostic turnaround times and pathways. This includes plans to support local areas to create extra capacity within NHS services to focus on more complex areas, such as cardiac surgery, and improve the service provision for the most clinically urgent patients.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

21/08/2024 A1

NHS England published the imaging reporting turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from the imaging examination and acquisition toa verified report being made available to the referring clinician. Caveats in the guidance include workforce capacity issues, as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and trainee radiologists per financial year, international recruitment initiatives and workforce demand and capacity planning tools. Since October 2021, over 120 Community Diagnostic Centres (CDCs) have also been opened across England to support access to diagnostic tests. To further support quicker access to diagnostic tests, NHS England published guidance in December 2023 for enhancing GP direct access to diagnostic tests for patients with clinical features of heart disease: NHS England » Enhancing GP direct access to diagnostic tests for patients with suspected chronic obstructive pulmonary disease, asthma, or heart failure. My regional colleagues in the North West have also been engaging with the NHS Greater Manchester Integrated Care Board (GM ICB) on the concerns raised in your Report, who I note you have also addressed your Report to. We understand that Manchester University NHS Foundation Trust (MUFT) have undertaken a High Impact Learning Assessment (HILA) regarding the care delivered to James, and have provided an assurance report to the ICB on the learnings taken and actions to implement changes. This has included a requirement to improve the cardiology referral-to-treatment (RTT) standard and the pathways for Transcatheter Aortic Valve Implantation (TAVI). Work on patient pathways across MUFT will feed into the Cardiovascular Strategic Clinical Network to inform how the ICB support and spread the work across the Greater Manchester system. There is currently a 15% radiology vacancy rate across Greater Manchester at Consultant grade level. The Greater Manchester Imaging Network are supporting upskilling and the change of skill mix within the imaging workforce by allocating funding for reporting radiographers, with a focus on CT and MRI reporting radiographers. The Network is coordinating international recruitment via the CDCs funding stream to bring in more radiologists. The Imaging Network are exploring the use of collaborative bank staff to reduce agency reliance. Your Report also raises a concern over the delays in communication between MUFT and Northern Care Alliance NHS Foundation Trust (NCA), including the fact that their IT systems are completely separate. The aim of the NHS England Frontline Digitisation (FD) Programme is for all secondary care Trusts to have an Electronic Patient Record system (EPR) that meets defined capability standards. The ability to access up-to-date patient medical records at any time increases safety, improves outcomes, and provides productivity benefits compared with paper records. A2

In 2022, MUFT secured funding to support levelling up capabilities following the acquisition of the North Manchester General Hospital site, to ensure the same level of EPR maturity as the other nine hospital sites within MUFT. Similarly, in 2022, NCA secured funding to level up EPR capabilities to the minimum specification by March 2025. This ongoing optimisation programme will address the concerns raised, as it will ensure NCA will transition various clinical sites to adopt the additional functionality and business capability. This transition includes Salford sites transition, which started in 2023 and is due to conclude in January 2025 NHS England through the FD programme is fully committed to supporting organisations through optimisation by providing a useful resource for Trusts. It provides a range of guidance and support from Subject Matter Experts and a library of support materials and blueprints, highlighting lessons learnt and implementation risks, although these are not vendor specific. Future plans include collaboration between the NHS England Patient Safety and Digital Clinical Safety Teams to take learning from incidents concerning EPR related patient safety and other relevant digital implementations, and to provide scenarios that Trusts can use to evaluate their systems and processes when preparing for their EPR implementations. GM ICB advise that there will be a request for leads for digital transformation programmes to look in more detail at improving the interface between secondary and tertiary care systems, and providers are working together to enable this. Learnings will be shared across the GM System Quality Group in November
2024. 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 James, 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 Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths

Thank you for your Regulation 28 Report dated 2nd of July 2024 regarding the sad death of James Cockburn. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Jame’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 29th of May 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern: -

The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence, patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.

Cardiovascular disease or CVD is a general term for conditions affecting the heart or blood vessels and includes angina, heart attacks, strokes, and heart failure. CVD has been identified as the single biggest area where our NHS can save lives over the next 10 years. Not only does it contribute to the gap in life expectancy between the rich and poor, it is also the leading cause of premature death and health inequalities across Greater Manchester (GM) where heart and circulatory diseases will kill more than 1 in 4 people.

Private & Confidential Ms Alison Mutch H M Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG

A5

NHS Greater Manchester The Tootal Buildings, 56 Oxford Street, Manchester, M1 6EU

NHS Greater Manchester ICB has a CVD prevention plan1 (based on the National CVD Prevention Recovery Plan 2022) and the key objective within this GM plan for CVD improvement is to support recovery from COVID-19 and return performance to pre-pandemic levels. This includes improving waiting times for patients to see a cardiologist and access to the key diagnostic tests.

This plan is overseen by the GM CVD Prevention Oversight Group and addresses the need to respond to the national CVD Prevention Recovery Plan and builds on our existing workstreams, structures and networks. It sets out an innovative, whole-system, population-health approach that empowers clinicians, non-clinical partners, patients, and communities across our system to work together to prevent CVD by providing alignment and co-ordination across different parts of the system.

Positive progress is being made on waiting times to access cardiac services and related diagnostic tests. However positive progress in relation to early detection and timely referral of patients at risk of CVD has increased demand on tertiary specialist referrals and related diagnostic tests. Progression of the NHS GM CVD Prevention Plan remains a key priority for NHS GM.

The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.

Radiologist shortages are being experienced nationally, with a 15% vacancy rate across Greater Manchester at consultant grade.

The Greater Manchester Imaging Network are supporting the upskilling and change of skill mix within the Imaging workforce by allocating funding for reporting radiographers, focusing on computerised tomography (CT) and magnetic resonance imaging (MRI) reporting radiographers. Furthermore, the network are coordinating international recruitment via community diagnostic centres (CDC) funding stream to bring in more radiologists.

The Imaging network are exploring the use of a collaborative staff bank, including CT, to reduce reliance on agencies etc. Also, the use of picture archiving and communication system (PACS) based reporting in future will be an enabler for an insourcing model or more centralised service to be used for reporting. PACS are Picture and Communication Systems, which provide economical storage and convenient access to images from multiple modalities and could therefore be used as central storage systems that can be used across GM, reducing the staffing resource required to do the reporting. The implementation of PACS is currently a key scheme within the Imaging Digital Programme.

In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.

Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners is a challenge. This is both at a Greater Manchester level and wider. We continue to work towards improving this as a system.

1 Greater-Manchester-Recovery-and-Prevention-Plan_final.pdf (england.nhs.uk) A6

NHS Greater Manchester The Tootal Buildings, 56 Oxford Street, Manchester, M1 6EU

Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR), a shared care record which amalgamates essential information for 2.8 million citizens and is used by health and social care professionals for direct care across the region’s 10 localities.

This shared care record is seen as a priority in the regional provision of care. The number of unique monthly users grew over 100% between April 2020 and December 2020 and continues to grow, with more than 4,000 patient records being accessed each day. Graphnet’s CareCentric shared care record software collates information from and provides information to over 500 health and social care organisations.

Data held in the shared care record includes:
• appointments and visits
• assessment and test information
• care packages
• critical clinical support requirements such as allergies, medications, and alerts

We acknowledge that there is still further work to do in relation to this and we will be challenging the leaders who support our digital transformation programmes to look in more detail at improving the interface between secondary and tertiary care systems and our providers in these sectors as to how they work together to enable this.

We will be sharing this learning at the Greater Manchester System Quality Group on the 19th of September 2024.

Thank you for brining this matter to our attention.

Best wishes

Chief Nursing Officer NHS Greater Manchester A7