Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ronald Henry Spencer who died on 2 December 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 April 2024 concerning the death of Ronald Henry Spencer on 2 December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ronald’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Ronald’s care have been listened to and reflected upon. 

Your Report raised concerns over staffing issues being experienced across the NHS and the challenges these cause nationally.

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. Your Report also raises the impact of delays to patient care being caused by ‘winter pressures’ and that there is ‘inadequate cohesive forward thinking or planning’ to short-term pressures such as these. NHS England continues to plan for and provide support to systems ahead of winter pressures. Further information and links to historic plans and letters to our systems can be found on our winter resilience website pages. For the most recent winter period (2023/24), we sent out a letter to our Integrated Care Boards and Trusts, setting out our national approach to winter planning and our four areas of focus:
1. Continuing to deliver on the Urgent & Emergency Care Recovery Plan by ensuring that high-impact interventions are in place. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

17 June 2024

2. Competing operational and surge planning to prepare for different winter scenarios.

3. Ensuring that there is an effective system working across all parts of a health system, including acute trusts and community care, elective care, children and young people, mental health, primary, community, intermediate, social care and the voluntary, charitable and social enterprise sector.

4. Supporting the workforce to deliver over winter. This followed the publication of our ongoing delivery plans for recovering Urgent and Emergency (UEC) Care services, Primary Care Recovery Plan and Elective Recovery Plan, all of which provide a strong basis for winter preparedness. Trusts do have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with the Care Quality Commission (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. I would therefore refer you to NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust for more local arrangements on staffing and workforce. However, NHS England understands that there have been several appointments since Ronald’s death and that there is now increased resilience in the emergency surgery rota and that recommendations are expected to be made regarding their oesophago-gastric service configuration. NHS England have been asked to be sighted on their final responses to the coroner. 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.

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: Prevention of Future Deaths – Ronald Henry Spencer I am writing in response to your Prevention of Future Deaths report dated 23rd April 2024, in relation to the recent investigation into the circumstances surrounding the death of Ronald Henry Spencer. NHS Birmingham and Solihull (BSol ICB) and University Hospitals Birmingham (UHB) would like to take this opportunity to offer sincere condolences to Mr Spencer’s family at this time and offer assurances that we have carefully considered the issues that arose during the inquest and will use this time to ensure that lessons are learned for patients and the public in the future.

In response to matters of concern in relation to staff shortages at UHB, it is noted that the Inquest found no evidence to suggest that the standard of clinical care provided to Mr Spencer contributed to his death. However, we recognise that at the time of his death there was an unprecedented strain on the general surgical consultant workforce at UHB as a result of unanticipated sickness absence of three surgeons. Steps had been taken to mitigate the impact of the exceptional workforce pressures which included arranging for two senior fellows, both of whom had completed registrar training, to "act up" and cover any identified gaps on the consultant rota. Both fellows were considered to be sufficiently skilled and experienced and consultant support was also put in place so that there was oversight of their temporary roles.

Since the time of Mr Spencer’s admission in December 2023, three locum consultants in emergency surgery have been appointed as well as an academic colorectal consultant. As a result, there is increased resilience in the emergency surgery rota than was the case when Mr Spencer was admitted.

It has also been recognised that the current staffing model in place, which includes four dedicated esophago-gastric consultants running the specialist upper GI on-call service for the region, may represent an additional vulnerability within the service, particularly at times of increased demand. The UHB upper GI service has recently undergone an independent invited review which has been conducted by the East Midlands Clinical Senate. The review encompassed all aspects of elective and emergency upper GI care at the QEH. The final report is awaited, but it is anticipated that recommendations will likely include reviewing the current esophago-gastric service configuration and increasing the number of consultants

covering the upper GI on-call rota. All recommendations will be considered and implemented, where appropriate, which will further support service resilience.

In addition to the above and recognising the impact of increased urgent and emergency admissions on our healthcare system, there are also plans underway to open the refurbished elective surgical hub at Solihull Hospital in September 2024. There has been significant investment in the hub which includes six new operating theatres and will enable an additional 11,500 procedures a year for patients from Birmingham and Solihull, thereby alleviating pressure on bed occupancy and treatment capacity across the Trust.

BSol ICB recognises the need for a workforce that is sufficient in numbers and skills to care for patients throughout the calendar year and works with all system partners to ensure this. We are also committed to the introduction of the NHS Long Term Workforce Plan.

In June 2023, BSol ICB carried out a high-level diagnostic of the current and future workforce looking at both demand and supply drawing upon BSol strategy and operational documents. It identified that workforce is an immediate and urgent priority for the ICB and supports the system in responding to the NHS Long Term Workforce Plan and Framework 15.

The workforce diagnostic recommended system-wide action in four areas using trend breaking action to help achieve in-year operational plans in terms of activity, finance and workforce. The actions fall into four workstreams (4R’s), these are:

• Reconnecting with our staff.

• Recruit, Retain and Train.

• Resilience - reduce reliance on contingent workforce actions including temporary staffing.

• Reform – redistributing skills and resources to deliver redesigned future services.

In October 2023, the BSol ICS Workforce Programme Board was established to provide oversight and support delivery of the 4R’s Workforce Delivery Framework, this group reports directly into the BSol ICS People Committee.

The 4R’s Workforce Delivery Framework is now operational and significant resource has been allocated to support implementation over the next two years. This investment will be used to sustain the delivery of existing programmes where they have been identified as supporting the 4R’s as well as a range of additional priorities identified as part of the Workforce Diagnostic.

The investment received will be used to:

• Implement the ‘new staff offer’.

• Deliver key programmes of work that have been identified as critical to address the risks and challenges identified within the workforce diagnostics which will enable:

o moving to a more sustainable workforce model with reduced reliance on temporary staffing. o investment in the retention of health and care workforce. o support system-wide training and development programmes. o setting the foundations for implementation of the NHS Long Term Workforce Plan.

The BSol ICB Finance and Performance Committee and People Committee receive detailed workforce data reports at their meetings. The reports focus on a range of workforce indicators including staff in post, vacancies, sickness absence and turnover with focused discussion on the actions to support organisations being taken at a system level including the 4R’s Workforce Delivery Framework. Where appropriate workforce, training and education issues are also discussed and reported via the BSol System Quality Group.

If we can be of any further assistance at this time, please do contact me.

Dear Mr Hodson,

Thank you for your Regulation 28 report to prevent future deaths dated 23 April 2024 about the death of Ronald Henry Spencer. I am replying as Minister with responsibility for NHS workforce planning.

Firstly, I would like to say how saddened I was to read of the circumstances of Ronald Henry Spencer, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over winter pressures in the hospital where Ronald received care, wider staffing pressures in the local area and planning to find longer term solutions to workforce shortages.

In preparing this response, Departmental officials have made enquiries with NHS England.

We recognise winter pressures are having a significant impact on UEC services. That is why, in January 2023, NHS England published a two year 'Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, with a target for this year to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at:

for-recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-
2024.pdf

To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.

£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was

also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.

Since publication of the recovery plan in January 2023, there have been improvements in performance. Nationally in 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of over 27%.

As of January 2024, there are 21,531 full-time equivalent (FTE) staff working in University Hospital Birmingham NHS Foundation Trust, which is 1,636 (8%) more than in 2023. This includes 2,882 FTE doctors and 5,289 FTE nurses which is 214 (8%) more doctors and 448 (9%) more nurses than in 2023.

The Surgical Specialty Group within the Trust has 38 (6%) more FTE doctors, and 260 (6%) more consultants in January 2024 than in 2023.

In addition, as of January 2024 there are 45,024 FTE staff working within NHS Birmingham and Solihull ICB, which is 3,127 (7%) more than in 2023. This includes 5,058 FTE doctors and 11,379 FTE nurses which is 313 (7%) more doctors and 649 (6%) more nurses than in 2023.

There are 1,033 FTE doctors working in the Surgical Specialty Group within the ICB, which is 52 (5%) more than in 2023. This includes 444 FTE Consultants, which is 24 (6%) more than in 2023.

The NHS Long Term Workforce Plan (LTWP) sets out the steps the NHS and its partners need to take to deliver an NHS workforce that meets the changing needs of the population over the next 15 years.

NHS England is working at a national level to deliver the LTWP. 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 includes ambitions 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 Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (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. I hope this response is helpful. Thank you for bringing these concerns to my attention.