Dear Mr Haigh Richard John LOCKLEY Further to previous correspondence , am pleased to provide a response to your report under paragraph of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Richard John Lockley. Recorded Circumstances of the Death Mr Lockley had throat and neck cancer: In June 2018 he fell at his home and broke his neck but still could mobilise_ On 26 2018, while attending County Hospital as an outpatient he fell and had to be admitted, He needed to wear a neck collar He was a complex case and suitable feeding had not been sorted out by the time he died in hospital on 11 September 2018_ Cause of death was given as 1a: aspiration pneumonia; 1b: C1/C2 cervical spine fractures_ Concerns During the course of the inquest H M Coroner, felt that evidence revealed matters giving rise for concern. In the Coroner's opinion there is a risk that future deaths will occur unless action is taken and the matters of concern are as follows: Mr Lockley's condition was a complex one but following discussions it was decided that he should be admitted to gastroenterology ward at the Royal Stoke University Hospital for radiologically inserted gastrostomy (RIG) Mr Lockley was at County Hospital There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke_
2. am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley: raise this just in case anything can be realistically done about this.

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Action Taken Following the inquest, the Trust has reviewed matters raised by H M Coroner and the following response outlines the Trusts position: 1 . In relation to optimising communication between our two hospital sites, it is agreed that Mr Lockley's pathway fell short of the standard of care that we hope to provide albeit, all the correct multidisciplinary services were involved in his care (ie radiology, gastroenterology, dietetics): Following discussion with the gastroenterology team and the imaging (radiology) team, there are some lessons that we have learned from this case and they include: There was a small window of opportunity to place Mr Lockley's RIG (in between episodes of aspiration pneumonia) and where this cannot be achieved, NG feeding should be commenced as first line treatment; RIG and PEG are never considered appropriate for urgentlemergency procedures_ This should have been communicated more clearly to the treating team. b When reviewing this case retrospectively, it is not imperative that patient has a bed on the gastroenterology ward for RIG placement and feeding many of the acute medical wards at the Royai Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is shortage of beds on particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered _ 2 Managing available beds across both sites is task which requires constant adjustment and supervision and the Trust has various measures to ensure that patients receive the appropriate treatment with minimal delay: This includes the measures below: If there is patient at County who requires procedures that are only performed at Royal Stoke, the Site Matrons and Matrons for Patient-Flow collaboratively arrange a treatment appointment at Royal Stoke_ book the patient transport; arrange treatment as for any other day patient and then arrange for transfer back to the ward at County following the procedure. This process has been followed on many occasions for different specialities_ If the patient requires an overnight bed at Royal Stoke due to the nature of the procedure being undertaken, then additional measures can be taken: All intra-Trust repatriations are assessed on daily basis and added to the Repatriation Board at the Site Office (both local patients and regional patients coming from external Trusts): Facilitation of a transfer is discussed three times per day at the Bed Meeting with the Site Matron and the Patient- Flow Co-ordinators; updates on transfers are discussed verbally between the Site Matrons on both hospital sites (ie County and Royal Stoke): Bed availability can change frequently and prioritisation of patient need is required for example, poly-trauma patient transferred from a tertiary centre to the trauma centre may mean that various bed moves need to be considered if the bed capacity is full. The Site Matron at County will communicate with the ward and escalate, within the Division, any significant delays in treatment: In addition to the above, the Trust is currently looking to 'RAG rate all requests to transfer patient based on clinical need and the wait for transfer, to support decision making and appropriate use of resources sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mr Richard

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John Lockley seriously_ The Trust strives to provide a high standard of care to all patients and am grateful to you for raising these concerns on this occasion. Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.