Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Holly May Mullan who died on 7 May 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 October 2023 concerning the death of Holly May Mullan on 7 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Holly’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Holly’s care have been listened to and reflected upon.

In your Report you raised the concern that following the COVID-19 pandemic, waiting times for gastroenterologist and gynaecologist had grown significantly across England. NHS England Women’s Health and Gastroenterologist professionals have been sighted on your Report and have contributed to this response.

The Delivery Plan for Tackling the COVID-19 Backlog of Elective Care sets out plans to reduce waiting times and improve patient experience for patients across all specialty areas, including gynaecology and gastroenterology.

NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised patient pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.

The GIRFT Further Faster Programme is also specifically looking at eradicating long waiting times from referral to treatment (RTT), in 16 different specialties. The specialties of Gastroenterology and Gynaecology both involved in the Further Faster Programme and have made good inroads into reducing long RTT waiting times in the first cohort of Further Faster Trusts (25 Trusts taking part), compared to the non-further faster Trusts. Of the 16 specialties involved in this programme, gastroenterology has shown the greatest impact (39% difference, as non-further faster trusts’ National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4 December 2023

gastroenterology numbers of 52+ week waiters increased by 122% by October 2023 with Further Faster Trusts reducing these to 83% of the starting figure from July 2023). The Programme has rolled out to a second cohort of 25 Trusts in November 2023 and will be disseminating lessons learned across the wider NHS. As part of the further NHS response to COVID-19, NHS England introduced the Clinical Prioritisation Programme. This sets out an expectation of clinical review of waiting lists, to enable patients with the most urgent conditions to be reviewed first based on the information available (such as urgency indicated at referral or decision to admit, procedure type, specialty, and length of time that the patient has been waiting for treatment). The guidance was developed with the Academy Of Medical Royal Colleges.

It is not clear from your Report or from subsequent questions to your office if Holly received any diagnosis for the pain she was experiencing or if she was eventually seen by NHS gynaecologists or gastroenterologists. If she was not on an admitted waiting list, but instead waiting for outpatients service her referral should have been triaged, although NHS England are not able to investigate this without further particulars. You may wish to contact the Trust to obtain further information.

The NHS is changing how it delivers outpatient services so that patients can be seen more quickly and can access and interact with services in a way that better suits them. We are giving patients and carers more control and greater choice over how and when they access care. We have recommended more use of patient initiated follow up (PIFU) pathways, which help empower patients to book their own follow-up care as and when they need it. We are encouraging services to discharge patients as soon as this is appropriate, with safety net advice, to reduce unnecessary follow up appointments. This allows those patients who do need to access appointments to be seen more quickly. We are helping services to reduce the number of missed outpatient appointments (did not attends or DNAs) to make the best use of all available appointments. As part of outpatient transformation, we are encouraging and enabling access to earlier expert advice through triage of referrals and by greater use of advice & guidance (A&G) or advice & refer (A&R) services. This allows patients and GPs to get the benefit of expert advice and treatment much earlier in the patient pathway. Patients who do not need to be seen in outpatients can continue to be safely managed in primary care, following specialist advice, or may be diverted direct to test where appropriate to facilitate an earlier diagnosis. This allows those that do need to be seen in clinic to get access to clinic in a much shorter timescale and will help reduce referral to treatment times for all patients. 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.