Dear Mrs Connor Re: Report to Prevent Future Deaths E Mercer 26.04.2024 Further to your prevention of Future Deaths Notice following the conclusion of your inquest (10.04.2024) into the death of Ellen Mercer who died on 10th February 2023, we would like to extend our sympathy and condolences to the family and friends of Ms Mercer. We note this unfortunate incident occurred in the setting of a prolonged stay in an emergency department (ED). As a medical royal college we have been raising concerns nationally for a considerable period of time regarding the adverse consequences of prolonged ED length of stay / ED Crowding. Our own publication highlights the consequences of ED crowding and its negative impact on adverse events, prolonged hospital stays, and increased mortality and morbidity [1]. Delays in assessment and diagnosis are features of crowded emergency departments; the Health Services Investigation Body (HSSIB) have published a series of reports which also highlights the impact of these same factors in patient safety incidents [2]. We note from your Regulation 28: Report to Prevent Future Deaths notice that you identify the delay in a risk assessment for the prevention (as opposed to treatment) of venous thromboembolism (VTE) being a concern and that the timing of the risk assessment may be subject to variation. As a medical royal college we have issued guidance on clinical responsibility for patients who are located in the emergency department but who have been seen by and are under the clinical care of a team other than the emergency medicine team. This guidance states “Once a patient in the ED is seen by a specialty team, then that patient becomes the responsibility of the specialty team” [3]. This guidance was issued to ensure that emergency department doctors are able to prioritise the assessment and treatment of newly arrived patients in a timely fashion. It is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process; this is the role of the admitting specialty doctors, even when the patient is still in the ED. We would however expect emergency department doctors to undertake a VTE risk assessment for those patients who are being admitted for a prolonged period under the care of the ED team to a clinical area such as a Clinical Decision Unit or Observation Ward run solely by the emergency department. We note your concern around the potential for confusion with regards the timing of the risk assessment however, as described above, these are issues for the admitting specialities and we feel it would be inappropriate to comment further. 4

Dear Mrs Connor, I write in response to your regulation 28 report, dated 26 April 2024, regarding the very sad death of Ms Ellen Mercer. I would like to express my sincere condolences to Ellen’s family. We have reflected on the circumstances surrounding Ellen’s death and the concerns raised in your report, specifically that policies do not require assessment of VTE risk in people presenting at the emergency department. In terms of our guidance, we have published a guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism [NG89]. The guideline makes recommendations for VTE risk assessment for people admitted to hospital and we recommend assessing all medical patients to identify the risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the first consultant review (recommendation
1.1.2). The scope of the guideline does not cover people in the emergency department prior to admission. We have therefore not made any recommendations that cover the circumstances described in your report. We have recently implemented an organisation-wide approach to prioritisation and topic selection. This is overseen by a single prioritisation board that guides the selection and coordination of our guidance development. We will ask our prioritisation board to consider if guidance should be developed in this area. Please do let me know if you require any further information and again, I offer my sincerest condolences to Ellen’s family.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ellen Mercer who died on 10 February 2023. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 April 2024 concerning the death of Ellen Mercer on 10 February 2023. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Ellen’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Ellen’s care have been listened to and reflected upon.  Your report raises concerns around increasing wait times within Emergency Departments (EDs) and the delays that that this can cause to patients undergoing venous thromboembolism (VTE) risk assessments while they await admission to a ward, and that the current policies do not take long waits in emergency departments into account. NHS England recognises the pressures that continue to be placed on Urgent & Emergency Care (UEC) services. In January 2023, we published the Delivery Plan for recovering urgent and emergency care services which set out our plans and ambitions to improve the service over the next two years. The plan commits to improvements in five key areas:
• Increasing UEC capacity
• Increasing workforce size and flexibility
• Improving discharge
• Expanding care outside of hospital
• Making it easier to access the right care. This includes patients being seen more quickly in emergency departments. An update on the plan, published in October 2023, noted that significant progress had been made, despite pressures on the service remaining high. The National Institute for Health and Care Excellence (NICE), who I note you have also addressed your Report to, are responsible for the relevant clinical guidelines [NG89] for VTE risk assessment. 13

The guidelines currently state that patients should be risk assessed as soon as possible after admission, with admission defined as ‘Admission in the context of this guideline refers to admission as an inpatient, where a bed is provided for 1 or more nights, or admission as a day patient, where a bed is provided for a procedure including surgery or chemotherapy but not for an overnight stay’. Following a period of consultation, the VTE risk assessment data collection restarted as of 1st April 2024. NHS England’s VTE Risk Assessment Guidance has been updated with the following: ‘To support the collection of data, NHS England has clarified that risk assessment should be completed on inpatients within 14hrs of admission; NICE guidelines state that where required, pharmacological thromboprophylaxis should be started within 14hrs of admission, therefore risk assessment should be completed prior to this, unless otherwise stated in the population-specific recommendations.’ We do not think it is likely to be effective to require ED staff, who are already experiencing issues with their capacity, to undertake a specific risk assessment for VTE. This is supported by the Royal College of Emergency Medicine (RCEM), who we note in their response to you, have stated that ‘it is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process’ and that this is the ‘role of the admitting specialty doctors, even when a patient is still in the ED’. The RCEM has issued clinical guidance on the clinical responsibility for patients who are located in the ED but who have been seen and are under the clinical care of another team. The guidance states that ‘Once a patient in the ED is seen by a specialty team, then the patient becomes the responsibility of the speciality team’. UEC colleagues at NHS England have also advised that they would view the admission process to start once a decision has been made to admit a patient and that an assessment for VTE should then be made, including if the patient remains in the ED. However, to further clarify this issue and acknowledging that there is an ongoing heightened demand in EDs leading to significant waits, NHS England’s national Patient Safety Team have been in touch with NICE to suggest that their guidance is updated to reflect that VTE assessments should be undertaken within 14 hours of a ‘decision to admit’, as opposed to admission. NICE have advised that they will be addressing the issue with their Prioritisation Board. I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. 14

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 Mrs Connor I write in response to the Regulation 28 Report you issued on 26 April 2024, following the inquest into the death of Ellen Mercer, which concluded on 10 April 2024. Your concerns were as follows:
1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one. In partnership with the Ministry of Defence Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 6

Meeting on 22 May 2024 On 22 May 2024 the Trust convened a meeting for key clinicians, clinical governance and legal colleagues to discuss the concerns raised in the Report and to consider how best to mitigate against the venous thromboembolism (‘VTE’) risk to patients in the Emergency Department (the ‘ED’) at Wexham Park and Frimley Park Hospital. The following colleagues were in attendance and contributed to the discussion: o Consultant in Haematology; o , Consultant in Haematology; o , Head of Quality and Clinical Effectiveness; o , Head of Legal Services; o , Chief Medical Officer; o , Consultant in Emergency Medicine and Chief of Service Emergency Medicine; o , Deputy Legal Services Manager for Wexham Park; o , Deputy Medical Director; and o , Consultant Respiratory Physician and Chief of Service for Transformation and Continuous Improvement. During the meeting the clinicians considered the concerns as detailed in your Report to Prevent Future Deaths, the Trust’s VTE Policy and the NICE guidance titled: ‘Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism [NG89] Updated 13 August 2019’ (the ‘NICE Guidance’). As was explained by at the Inquest hearing, the Trust’s approach to VTE risk assessment has been informed by the NICE Guidance. However, the clinicians agreed that owing to unprecedented demand on services there are now patients waiting for far longer in ED than was perhaps contemplated when the NICE Guidance was drafted (which requires at paragraph 1.1.2 that medical patients should be assessed for risk of VTE and bleeding as soon as possible after admission or at the time of the first Consultant review), as was recognised at Ms Mercer’s inquest. Prior to the meeting, had made enquiries of colleagues at a neighbouring Trust to understand their working practices in relation to VTE risk assessment and shared her In partnership with the Ministry of Defence Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 7

findings by way of email. I understand a neighbouring Trust has opted to depart from the NICE Guidance and has instead moved to ensuring VTE risk assessments are completed for patients in the ED who have been present for 12 hours or more. It is understood that their electronic patient record keeping system prompts clinicians to action the VTE assessment at the relevant time and a safety dashboard system is used to highlight patients requiring particular care interventions including VTE risk assessments. At the meeting the clinicians agreed in principle that patients attending the ED who have been present (for whatever reason) for 12 hours or more should be subject to a VTE risk assessment. It was acknowledged that the finer detail of the Trust’s revised policy would need careful consideration and all were particularly mindful of the impact of adding to workloads of ED staff in the absence of additional resource. Trust’s Proposals The Trust is taking the concerns raised seriously and is committed to updating its VTE Policy so that VTE risk assessments are completed for patients who have been in ED for periods greater than 12 hours from arrival. It is recognised that the VTE Policy will also need to be revised to cover timescales for administration of any pharmacological VTE prophylaxis to be given to patients as appropriate (to reflect paragraph 1.1.4 of the NICE Guidance which states this should be given as soon as possible and within 14 hours of admission unless otherwise stated in recommendations). It is envisaged the following steps will be needed to effect the necessary changes:
• Consideration as to whether there may be patients who attend the ED for whom VTE risk assessments are not required and if so, how those patients can be screened out by using specific exclusion criteria.
• Consideration of who/ which speciality will complete the VTE risk assessment once the 12 hour mark has been reached, as required; o It is envisaged that where the patient has been referred on by ED, the speciality in receipt of the referral will be responsible for completing the assessment at the relevant time.
• Updates to the wording of Section 2 of the Trust’s VTE Policy; In partnership with the Ministry of Defence Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 8

• Work with the Electronic Patient Record team to make changes to the Trust’s electronic record keeping system, EPIC, so that a prompt is generated at the relevant time; and
• Trust wide communication to be circulated by email explaining the changes to the policy, the Epic prompt and the rationale for the same. In due course the Trust will also need to update the Data Quality Improvement Plan in order to assess the effectiveness of the changes and inform consideration as to whether any further steps are needed to ensure the revised practice is embedded successfully across the Trust. The committees that will oversee progress will primarily be the VTE committee who meet every other month and also report into Patient Safety Steering Group (PSSG) quarterly. Care Governance Committee and quality assurance committees have oversight of the VTE committee’s work and PSSG’s reviews of VTE performance. Route to change In order to progress the above steps, the Trust has assembled a working group who will have responsibility for the amendments to the policy and the plan for rollout. The intention is for the group to meet fortnightly and for a representative to feedback to the afore mentioned VTE committees as to the group’s progress. The Trust intends to complete the necessary steps as described above within 12 weeks (by 12 September 2024). I do hope the above provides sufficient reassurance as to the Trust’s ongoing commitment to patient safety and continuous service improvement. Please do let me know if any further information would be of assistance.

Dear Ms Connor

Report to Prevent Future Deaths E Mercer 26.04.2024

We note the content if your Regulation 28 report for the prevention of future deaths related to the death of Ellen Mercer.

We send our sincere condolences to the family.

You note prolonged delay to be admitted to hospital, and the consequent delay in receiving prophylactic therapy for venous thrombo embolism. This may have resulted in fatal pulmonary embolism. You also note that current guidance is for this to be assessed within 24 hours of admission. In the current circumstances with substantial delays in patients being admitted from emergency departments, sometimes for more than 24 hours, this creates delays in treatment that can be life-saving.

We note that the Royal College of Emergency Medicine has produced guidance on the clinical responsibility for patients who have been accepted for admission. Unfortunately this guidance was produced without endorsement from admitting specialities, and therefore may not have been widely implemented.

Each hospital will differ in the delays for admission, and the relative capacity of clinical teams.

In the current context of delays for admission we do not believe that timing interventions from admission is appropriate, and these should be modified as timings from attendance or speciality referral. Each hospital should have a local policy that agrees on clinical responsibility for patients waiting for admission in Emergency Departments.

In light of this case we will produce a Safety Alert for Physicians, and also liaise with NHSE England National Clinical Director for Urgent and Emergency Care, National Clinical Director for Patient Safety and The Society for Acute Medicine.