Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Patricia Ann Walton who died on 9 January 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 December 2023 concerning the death of Patricia Ann Walton on 9 January 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Patricia’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Patricia’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 Patricia’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

In your Report you raised the concern that there was insufficient medical staff cover over the New Year Bank Holiday period while Patrica required care. You raised that while there might be a doctor available on call to treat emergencies, there is not suitable cover to assess the subtleties of care required by patients who do not require emergency care.

In 2016, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whichever day they attend at hospital.

The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need.

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

23rd February 2024

Workforce and staffing levels continue to be a challenge across the NHS and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history.

NHS England has engaged with University Hospitals of Leicester NHS Trust (UHL) on the matters of concern raised in your Report and has also been sighted on their response to the coroner. We note that they advise that they have already increased medical staffing at Leicester Royal Infirmary and that during bank holiday and weekends periods they are rostering for a medical consultant to be present 9am to 5pm onsite, a medical registrar onsite 24hr/7days a week and by a junior doctor onsite 24hrs/7days a week. We also note their escalation policies for staff concerned about deteriorating patients and that they plan to deliver an anticoagulation review service going forward. 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 His Majesty’s Coroner office for Leicester City and South Leicestershire:

We would like to acknowledge the concerns raised in the Regulation 28 report, and once again offer our apologies for the error in the management of dual anticoagulation which led to haemorrhage for Patricia.

We have put in place robust measures to prevent a similar error in the future, including:

• Changes to the way anticoagulation is prescribed in our electronic prescription system.
• Recruiting new staff to deliver a robust specialist trust wide anticoagulation review service during core working hours.
• Anticoagulation is one of our key learning points for the new NHS Patient Safety Incident Response Framework (PSRIF) starting in April 2024.

In relation to the preventing future deaths action regarding medical staffing. We have already increased medical staffing at the site where the incident occurred. During bank holiday and weekend periods, we are rostering for a medical consultant to be present 9am to 5pm onsite, the consultant is supported by a medical registrar onsite 24hr/7days a week and by a junior doctor onsite 24hrs/7days a week.

Across all our sites, patient safety is the paramount focus for all staff. We employ several escalation policies for any staff member to raise concerns regarding any patient at any time, including:

• Early deterioration in physiological parameters (Early Warning Scores).
• A clear handover process for nursing teams when patients are transferred between wards.
• An experienced trust wide deterioration patient team who responds proactively to help support clinical teams.

Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this did not impact on her care. Irrespective of the time of year, based on the clinical deterioration triggers there was no cause to raise clinical concerns sooner during her admission. If Patricia’s clinical condition had worsened earlier, our escalation policies

2 would have ensured a clinical review took place, regardless of the bank holiday weekend staffing levels.

To strengthen our deterioration response, as of the first week in February 2024, the board has approved, through the deteriorating patient team, patients and relatives will be able to request an independent clinical review of care if they have unresolved concerns about potential deterioration. We are also working towards making it clearer and easier for patients and families to formally make their concerns known to clinical staff through better documentation of their ideas, concerns, and expectations.

We have reviewed the potential for increasing our medical workforce across all our sites during bank holidays and weekends. However, as is the case for all other NHS trusts, there are considerable workforce challenges that limit us in our ability to maintain a consistent number of inpatient medical staff 7 days a week, 365 days a year. These challenges become particularly acute during public holidays when our staffing levels reflect the social cultural context of UK society taking holidays, especially during the winter holiday period.

Time shifting our medical workforce to allow a more even distribution between normal days and weekend/bank holidays would bring significant disruption to our existing elective services including needing to cancel elective operations and outpatient resources, meaning more patients are placed on our waiting lists. However, despite these challenges over the Christmas and New Year period between the 23rd of December 2023 to 1st of January 2024 we had at least 350 medical staff rostered to provide inpatient care across our hospitals.

We continue to develop innovative ways to improve patient safety within our allocated resources and will work with the national team to explore all options to address workforce challenges.