Dear Dr Harris, Inquest touching the death of Derek Weaver am writing on behalf of Guy's and St Thomas' NHS Foundation Trust (the Trust) in response to the Regulation 28 Report to Prevent Future Deaths (PFD Report) dated 16 October 2019 following Mr Weaver's inquest on 3 October 2019. In the PFD Report; you expressed the matter of concern as follows: A consultant thoracic surgeon who was involved in his care after transfer said that he had a higher chance of death because surgery was at a time of SIRS If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages: the first being key-hole surgery, with mortality of only in 100_ That have obviated the necessity of second stage decortication surgery with mortality of 5%, but it was probably needed anyway: The delay in transfer related to a surge in referrals , capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week: There had been pressure to secure greater resources_ The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by the provision of more beds_ The Trust response to the matter of concern Thank you for giving the Trust the opportunity to respond to the concern raised in the PFD Report. The Board and take this issue particularly seriously and am that this issue may have contributed to Mr Weaver's death. Set out below is the context of our Thoracic Surgery Service and the improvements that we have implemented to mitigate any future risk may limiting sorry

The Trust's Thoracic Surgery Unit The Thoracic Surgery Unit at Guy's Hospital is one of the largest in England both by consultant numbers (currently 6) and activity. It currently performs over 1500 cases year, approximately 600 lung cancer resections per annum (representing almost 9% of all cases in England and Wales) and provides advice to other hospitals within large geographical area (South East London, Berkshire, Kent and large part of East Sussex) for patients potentially requiring non-elective and emergency thoracic surgery intervention. significant number of patients (approximately 200 year) are referred as emergencies or for consideration of in-patient transfer; if their clinical condition requires urgent intervention. Pressure on beds , and to a lesser degree_ theatre capacity in relationship to increased activity year 0n year; has meant that it is not uncommon for patients to wait for several to transfer in if are clinically stable. At certain times of the year when influenza and bacterial pneumonias are endemic the number of referrals will often increase and these patients are often septic and unwell: The management of transfers in 2018 At the time of Mr Weaver's death in May 2018 the Thoracic Surgery Service operated "consultant of the day" system. Each day the duty consultant was responsible for reviewing all new referrals and patients already accepted to determine urgency and priority for available beds; The Service required all referral requests to be made by email using the secure NHS mail system so that an electronic record of discussions was available to staff, It was usual practice to advise referrers to update the Unit if there was a clinical deterioration_ At this time the Thoracic Surgery Service also managed their own bed allocation, including beds for elective activity, tertiary referrals and urgent transfers_ The management of transfers in December 2019 In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a "consultant of the week" system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service_ The "consultant of the week" system will be audited to ascertain whether it has improved the management of transfers in_ In October 2019_ to mitigate the risk of capacity issues impacting on transfers, the Directorate Management Team transferred the management of the Thoracic Surgery Service's beds and urgent transfer process to the Site Management Team: This change aligned the Thoracic Surgery Service with other services across the Trust: The process, set out in the UTCI Flow Chart (appendix 1), enables the Thoracic Surgery Service to triage its patients into three categories (1) Admission not urgent;, (2) Urgent Needs admission within 48 hours and (3) Urgent Needs admission immediately and for the appropriate transfer to be arranged. When a patient is identified as 'Urgent Needs admission within 48 hours' , the Adult Urgent TCI Request Form (appendix 2) is completed, sent to the relevant Site Nurse days they May

Practitioner (SNP) Team: The patient's details are then added onto an Excel spreadsheet; which is a live document. Once bed is available, the SNP will contact the patient either at home or via the staff at the relevant healthcare provider to arrange admission and the patient is transferred in_ This process enables the central SNP team to respond to demand appropriately and to have oversight of current waiting lists. If bed pressures increase in Thoracic Surgery Services, the SNP team, which has an overview of all available beds on the s site_ can proactively move suitable patients to alternative beds at Guys' Hospital to facilitate more transfers in to the specialist service The Trust is looking towards an electronic referral system that allows local specialist services to manage their own tertiary referrals and gives the Site Management Team an overview of the current wa list In addition, the Trust Operational Board is currently looking to increase the number of beds on the Guy's Hospital site for Thoracic Surgery patients_ This will be achieved through switching the wards on which services are provided and undertaking the necessary estate works. It is expected that the increased capacity will be available during the first quarter of 2020.

Nadine Dorries MP Parliamentary Under Secretary of State for Patient Safety, Department Suicide Prevention and Mental Health of Health & 39 Victoria Street Social Care London SW1H OEU 020 7210 4850 Your Ref: 01562-2018 Our Ref: PFD-1194553 Dr Andrew Harris HM Senior Coroner; London Inner South HM Coroners Court Tennis Street Southwark London SE1 1YD Qk March 2020 Mv Acwv ), Thank you for your letter of 16 October 2019 to Matt Hancock about the death of Mr Derek Weaver: am replying as Minister with responsibility for patient safety and | apologise for the delay in replying: Firstly, would Iike to say how saddened was t0 read the circumstances of Mr Weaver's death and extend my sympathies to his family and loved ones: We must do all we can to ensure that the NHS provides high-quality, safe services and taking the learnings from incidents, such as the sad death of Mr Weaver; is key to ensure necessary improvements are made and future deaths are prevented. Departmental officials have worked with NHS England and NHS Improvement (NHSEI); which is responding separately to your report; to prepare this response am advised that NHS England's national Specialised Commissioning Quality Team has undertaken peer review and surveillance activities of thoracic services in London, including at the Guys and St Thomas's NHS Foundation Trust where no serious quality or safety concerns were identified. am further advised that NHSEI will maintain oversight to ensure patients requiring thoracic surgery can access the service in a timely way, according to their clinical condition. This will include reviews of bed capacity in response to the ambition set out in the NHS Long Term Plan, for earlier and faster diagnosis of cancer' and the impact this might have on related services such as critical care beds am aware that the and St Thomas' NHS Foundation Trust responded to your report with information on the measures it has taken to improve the triage and management of patient transfers and referrals so that are clinically prioritised. also https llenglandnhs uklcancerlstrategyl From Guys has they

understand that the Trust is looking to increase the bed capacity of its Thoracic Surgery Unit to better meet the needs of patients: Finally, note from your report that it took several months to receive medical records and other material from East Sussex Healthcare NHS Trust While do not know the circumstances in this case, want to provide assurance that NHS trusts have a legal duty of candour? to act in an open and honest way when there are investigations into the death of a patient in their care, as well as legal duties to provide all relevant information to support coronial processes. This was reinforced in a communication by NHS Improvement to NHS trusts in 20163. hope this response is helpful. Thank you for bringing these concerns to my attention. NADINE DORRIES httos Ilwww.cqc org Luklquidance-providerslrequlations-enforcementregulation-20-duty-candourttfull-regulation https llimprovement nhs uklresourceslduties-relating comner-inquestsl the

Dear Mr Harris , Re: Regulation 28 Report to Prevent Future Deaths Derek Weaver (date of death 31/05/2018) Thank you for your Regulation 28 Report (hereafter "the report' dated 16 November 2019 concerning the death of Mr Derek Weaver on 31
2018. Firstly, would like to express my deep condolences to Mr Weaver's family: The report concludes Derek Weaver's death was as a result of natural causes but was contributed to by a 14 day delay in transfer for surgery which was related to exceptional pressures on bed capacity Following the inquest you raised concerns in the report to NHS England regarding surgery occurring at a time when the patient was septic. If the surgery had happened earlier when he was not septic, the procedures which would have been used have a lower mortality probability As you identified the delays in referral and treatment were related to a surge in referrals at the time, which unfortunately limited capacity. As a result you consider that the risk of potentially preventable deaths will reoccur in the future whenever there is such a surge and could be mitigated by an increase in bed capacity_ In relation to the specific question on capacity to transfer a patient from a District General Hospital to the Guys and St Thomas Trust (GSTT) cancer centre, can confirm that there have been several regional assurance activities in relation to the quality and safety of thoracic services in London: The National Specialised Commissioning Quality Surveillance Team (QST) undertook peer review visits for Lung services in 2017_ Continue.
1.2 May

Please note no immediate risks were identified in the service at GSTT following this review: Furthermore, later assessments in 2018/19 by the QST team and through our annual surveillance exercise also did not identify any ongoing serious quality or safety concerns at GSTT. Although not specific to assessing the overall bed balance and its appropriateness the review did look at pathways and patient flow; that is, from a district general hospital to specialist (tertiary) care hospital. However; that being said we would recognise that currently GSTT is not meeting national targets for the 62-day cancer target and this failure is subject to oversight by commissioners with an action plan designed to ensure compliance: Within London we do have other thoracic providers (eg. University College Hospitals and Imperial Hospitals amongst others) so there is possibility to change the thoracic surgery pathway for both lung cancer patients and patients with conditions such as empyema that require urgent surgery too, if we felt insufficient progress was being made on meeting the nationally set response standards We can confirm we will keep this under review as we recognise the importance of making sure that all patients needing thoracic surgery can get quick access to high quality services_ With the new national pilots to identify lung cancer at an earlier stage we recognise that we will need to review capacity and ensure that we have sufficient critical care beds to support what we know will be more patients accessing treatment We will be actioning this in the light of new policy and due to the concerns raised by yourself as a result of Mr Weaver's death_ We have attached as an Appendix a short description of assurance processes that have taken place over the past two years and their findings. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information: