Edward Argar MP Department Minister of State for Health of Health & 39 Victoria Street London Social Care SW1H OEU 020 7210 4850 Your Ref: 1629209 Ref: PFD-1239582 Ms Alison Patricia Mutch HM Senior Coroner; Manchester South HM Coroner's Court Mount Tabor Street Stockport SK1 3AG 23' September 2020 J~ m Aun Thank you for your letter of 13 July 2020 to Matt Hancock about the death of John Cheetham: am responding as Minister with portfolio responsibility for NHS operational performance, including emergency care and winter planning and am grateful for the additional time in which t0 do so. Let me start by offering my sincere condolences to Mr Cheetham's family and loved ones; was saddened to read about the circumstances of Mr Cheetham's death; The length of time Mr Cheetham spent in the emergency department at Stepping Hill Hospital, Stockport is clearly unacceptable and fall and the injuries he sustained there, are deeply regrettable It is important that we take the learnings from Mr Cheetham's death to improve the safety and quality of NHS care. My officials have made enquiries with the Care Quality Commission (CQC), the independent regulator of quality, and NHS England and NHS Improvement (NHSEI) and am aware that regulatory action was taken by the CQC following an inspection at Stepping Hill Hospital in January and February this year: The CQC's inspection looked at urgent and emergency services, among other services, and identified significant concerns similar to those identified in your investigation of Mr Cheetham's death: The CQC found that people were not always kept safe and were at high risk of avoidable harm during periods of heavy demand on urgent and emergency care services Emergency care was consistently unable to be provided in a timely way; and there were significant issues with the flow of patients through the emergency department and the Hospital. The report of the CQC's inspection is available on its website? ,. It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport: https:llwww cgC_org uklproviderIRWJ From Our very his

am advised that following the CQC's inspection, health system partners in Stockport formed a system improvement board, that has representation from CQC and NHSEI, to oversee the implementation of an improvement plan to address the concerns identified. expect this work to also take into account the findings of your investigation into Mr Cheetham's death: My officials have brought the concerns in your report to the attention of NHSEI and the CQC. am assured that progress is being closely monitored by the Trust Board and that the CQC is also monitoring progress and conducted a follow up inspection in August 2020. would like to explain the national level action we are taking to support the NHS to respond to the year-on-year increase in demand on NHS services and in particular, alleviate the impact of increased activity in winter. In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in timely and safe manner: For example; the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital. This year; we provided an extra E3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS's use of independent sector hospital capacity: Other elements of the NHS winter plan for 2020/21 include 'NHS 111 First' which will provide low complex care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E? NHS Trusts across England, including the Stockport NHS Foundation Trust; will receive a share of E3OOmillion additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19. The NHS Long Term Plan? , published in January 2019, is supporting the reform of urgent and emergency care services to ensure that patients get the care they need quickly, relieve pressure on A&E departments, and manage winter demand spikes. The NHS Long Term Plan is supported by an NHS budget increase of E33.9billion in cash terms by 2023/24. This year we made E1.3billion funding available via the NHS to support the hospital discharge process in March As part f the E3billion funding for winter, an extra Es88million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital httpslenglandnhs uklurgent-emergency-carelnhs-11 next-steps-for-nhs-1L1L https l longtermplannhsukt the have

We know that adult social care capacity can become increasingly pressured over the winter months and this can have a knock-on effect on NHS hospitals It is important that suitable packages of care are available to ensure that patients who are medically fit to be discharged are able to return home and into their communities This frees up hospital beds and ensures that people who really need hospital care, receive it Despite the fact that the NHS is busier than ever before, with hospital admissions rising by 18 per cent from 2009/10, the majority of patients are discharged quickly: Both the NHS and social care services have been working hard to reduce delays and free up beds: It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly: Discharge arrangements from hospital should start well before a patient is actually ready for discharge, and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays. The NHS Long Term Plan commits funding worth €4.Sbillion per year by 2023/24 to be focused on primary and community care: This includes a national roll-out of support for care home residents s0 more people can be looked after where live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge: In relation to the matter of concern in your report about a shortage of nurses trained to work in emergency departments, would like to assure you that ensuring the NHS has the staff it needs, especially our nursing staff who are the absolute bedrock of the NHS and care system, is and will remain, a priority for this Goverment That is why we made our manifesto pledge to deliver 50,000 more nurses in our NHS by 2025, which we will achieve through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS, In relation to emergency nursing specifically, the Health Education England (HEE) 'Securing the Workforce strategy4, confirmed that the emergency department registered nursing workforce had grown by 17 per cent, from 12,491 to 14,613 WTE between 2012 and 2017. More recent figures show that between March 2019 and March 2020 there was a 7.2 per cent increase in the number of full-time equivalent nurses working in A&Es However; we know that attendances and admissions have continued to rise, as has the overall complexity of the needs of patients. httos llimprovementnhs ukldocuments/1826/Emergency_department_workforce_plan 111017 Final 3 pdf Figures published by NHS Digital in its NHS Workforce Statistics publication show the number of full time equivalent (FTE) nurses reported as the Area of Work 'AGE' at March 2020 was 15,593, an increase of 7.2 per cent from March 2019. This includes paediatric A+E nurses. httos Ildigitalnhs ukldala-and: informationlpublicationslstatisticallnhs-workiorce-statisticslmarch-202 Note the definition used for A&E staff by HEE is not consistent with the definition used t0 present changes over the past year. they having

Emergency Nursing is a graduate career choice, and while there is no NMC6 mandated post graduate education for nurses who choose to work in emergency departments, HEE supports post graduate learning through the Workforce Development and Workforce Transformation Funding and more recently with increased Continuing Professional Development allocations of E1,000 per registrant over three years. In addition, HEE has worked with the Royal College of Emergency Medicine to develop an education and training pathway to credential advanced practitioners alongside masters' level education and standardise the development pathway for more senior nurses in the emergency department: Finally, with regard to falls prevention, the National Institute for Health and Care Excellence (NICE) has published a clinical guideline on Falls in older people: assessing risk and prevention (CG1617) that includes guidance on preventing falls in older people during a hospital stay: The guideline says:
1.2.2.1 Ensure that aspects of the inpatient environment (including flooring: lighting, furniture and fittings such as hand holds) that could affect patients' risk of falling are systematically identified and addressed This recommendation would apply to wards, toilets and other parts of the hospital: The guideline recommends that for patients at risk of falling in hospital, an assessment of the patient's individual risk factors should be conducted and where necessary, appropriate intervention put in place: NHS trusts are expected to take account of NICE guidelines when planning care. hope this response is helpful Thank you for bringing your concerns to my attention. 2x ~X T' EDWARD ARGAR MP Nursing and Midwifery Council. https Ilnice orguuklquidancelcg161 post

Dear Ms Mutch I would like to advise you that Dr has left the Greater Manchester Health and Social Care Partnership which is why I am responding to your concerns in his stead. I am writing in response to the Regulation 28 report you issued on the 13th July 2020, following the inquest into the death of John Cheetham at Stockport Hospital. You raised a number of concerns and requested a response to confirm actions taken and any further proposed actions. I have responded to each of your individual points below.

Points 1 and 2 – high levels of demand and Emergency Department capacity The national and local pressures on the urgent and emergency care system have been well publicised during the course of the last year, with Greater Manchester experiencing significantly higher levels of attendances during the winter months. Attendances were, on average, 9% higher than the previous year which is about an extra 9000 attendances per month across Greater Manchester. This also resulted in a higher number of patients requiring admission to acute hospital beds and therefore crowding and delays within Emergency Departments. As a result of this, the Greater Manchester Urgent and Emergency Care (UEC) Transformation Board agreed a revised transformation plan in early January this year with two principle ambitions:

• To reduce attendances to Emergency Departments (ED) by improving access to, and utilisation of, primary and community-based services by rapidly developing and testing a GM ‘UEC by Appointment’ model
• By April 2022, we will reduce:
• Ambulance attendances by 100 per day across GM
• ED walk in attendances by 300 per day across GM The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:
• Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department
• A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go to an Emergency Department. A large proportion of patients will receive early local clinical assessment prior to being referred which will help ensure safety. We estimate that the new models of care will reduce Emergency Department attendances by around 900 per day across Greater Manchester. It is also worth noting that GMHSCP has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.

Point 3 – hospital bed capacity and the discharge of patients As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within Greater Manchester. The purpose of the guidance is to improve the flow of all patients being discharged from acute care and to help ensure patients’ needs are assessed in the home or usual place of residence. The guidance is also designed to improve consistency across organisational and geographical boundaries, thereby minimising unnecessary delays for patients. To help improve the consistency and operation of the pathways at the interface between different organisations, it has been agreed that the following elements of the guidance are required to be implemented by all localities:

Adoption of a single GM Discharge to Assess Referral Form
• Triage of discharge to assess referrals within 30mins
• Adherence to the guidance for COVID 19 testing for discharge and PPE requirements
• The supply of 2 weeks medication supplies at the point of discharge from an acute hospital
• Operation of a next day follow up process following discharge (localities to determine how this is delivered) The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. As a result, there has been a significant reduction in the proportion of long stay patients and acute hospital bed occupancy levels across all Greater Manchester sites. This has helped to improve flow from Emergency Departments and therefore helped reduce crowding. Bed occupancy is currently on average 83% across Greater Manchester, which is at least 10% lower than the same period last year.

Point 4- nursing workforce Nurse recruitment and retention is a priority for the Greater Manchester system and work is underway with Greater Manchester service colleagues, NHSE/I and Health Education England, in order to maximise opportunities for improved nurse staffing in all localities. The GMHSCP executive workforce lead is planning to meet with the Stockport Trust HR lead over the next month and will agree any further support that is required. I am also aware that Stockport Trust have recently recruited 30 nurses following an overseas recruitment exercise. These staff will be used to improve ward staffing levels which will also have a positive impact in terms of ongoing care and flow of patients. The national Emergency Care Intensive Support Team (ECIST) have also recently completed a review of Emergency Department Staffing and agreed a plan with the trust to make improvements ahead of winter.

Point 5 – risk assessment of patients in the Emergency Department Ensuring patient safety and quality of care in Emergency Departments, particularly in times of increased pressure, is highly important in Greater Manchester. All of the acute trusts in Greater Manchester now utilise a patient safety checklist in their Emergency Departments. These checklists are time-based frameworks that outline clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to improve patient satisfaction and reduce risks. These have been adopted from the national checklist template which was published in 2017 and which has been proven to improve clinical processes and reduce harm and serious incidents from unrecognised patient deterioration. In addition to this, clinical leads from Clinical Commissioning Groups

(CCGs) in Greater Manchester carry out regular walkrounds of their respective acute trusts and as part of these, usage of the checklist is monitored. I hope this response is satisfactory and provides sufficient assurance on the work we have undertaken to help mitigate risks to patients in the future. Your sincerely

Interim Chief Officer, Greater Manchester Health and Social Care Partnership