Dear Sarah Re: Regulation 28 Report to Prevent Future Deaths William following an inquest into the death of John Abrahams Thank you for your Regulation 28 Report ("Report") dated 17 January 2018 concerning the death of William John Abrahams on 28 August 2017 . would like to express my deep condolences to Mr Abrahams' family: The Report concludes William John Abrahams death was a result of natural causes with medical cause of death recorded as a ruptured abdominal aortic aneurysm: Following the inquest you raised concerns in your Report to NHS England regarding (1) Mr Abrahams was not invited for screening to check whether he had an Abdominal Aortic Aneurysm (*AAA"); as he was over 65 at the time that the screening programme was introduced. (2) Only about 20% of people that have a ruptured Abdominal Aortic Aneurysm survive (3) As Abdominal Aortic Aneurysms are asymptomatic until they begin to leak, the benefits of 'opting in' to the screening programme may not be apparent to patients. With regards to 1, men are currently invited to NHS Abdominal Aortic Aneurysm Screening Programme ("NAAASP") in the year they are 65. The programme was introduced in England in 2009 on the recommendations of the UK National Screening Committee ("UKNSC") following review of research evidence and data from existing local screening programmes against specific criteria This evidence showed a reduction in deaths from aneurysms when men were offered screening in their 65th year. Subsequently the UKNSC concluded that the ultrasound screening should be offered to men in their 65th year with men over 65 being able to self-refer or 'opt in' and request screening_ Criteria for appraising the viability effectiveness and appropriateness of screening programme PHE October 2015: https:/ /www gov uk/government/publications/evidence review-criteria-nat onal-screening programmes/criteria-for-appraising-the- viabllity effectiveness and-appropriateness-of-a screeming programme Implementation of the National Health Service Abdominal Aortic Aneurysin Screening Programme in England. Davis et al 2013; https: / /www ncbi nlmnih gov/pubmed/23523277 High quality care for all, now and for future generations IxehF point

All NHS screening programmes are implemented on the recommendations of the UK National Screening Committee ("UKNSC") which oversees screening policy in the UK. Recommendations are made to initiate screening programmes that target a defined group of the population which has been identified as being at risk and would benefit most from the screening test The North East London NAAASP began in April 2013. At this time Mr Abrahams was 81 years and would therefore not have received an invitation to have AAA screening: However he would have received screening had he asked for an appointment. When there is new evidence that brings current recommendations into question, the UKNSC has a set process for review of this new evidence including consideration of the eligible age of those invited. The NAAASP is led and coordinated in England by Public Health England including the development of the national service specification, quality standards and national programme awareness campaigns and patient information and promote informed consent in men aged 65 and over. NHS England is responsible for commissioning the programme according to the national service specification. The specification reflects the recommendations and sets out the requirements for delivery of the screening programme_ To address your concern as detailed at point 2, research shows that offering men ultrasound screening in their 65"h year should reduce the rate of premature death from ruptured AAA by up to 50 per cent: In January 2016 the National AAA Screening Programme had screened over one million men in England and over 10,000 aneurysms had been detected that need monitoring or trealment. 2000 of these were large aneurysms, requiring urgent surgery: Men that are found to have an aneurysm during AAA screening are referred to specialist vascular hospital services for further assessment, monitoring and if required surgery to treat the aneurysm: Men with screen detected aneurysms wiil see a nurse specialist for health assessment and health improvement advice and will either be referred for treatment or monitored with regular screening through the surveillance programme. Their risk is increased by smoking, high blood pressure or through close family history: With regards to your concern at point 3, during 2012-13 the North East London AAASP Communications and Engagement Plan promoted the launch of the programme in April 2013_ This was targeted at men aged 64 years and older; their families, friends and carers; as well as programme partners in the area (e-g: GPs, care home workers, district nurses, religious organisations, voluntary sector) who may be able t0 support the screening service by encouraging patientslpeople have caring responsibilities for or friends or neighbours who are eligible to take up screening UK NSC: Evidence review process PHE Sepl 2015.https:/ /www gov uk/government/publications/uk nsc evidence-revrev- process/uk nsc-evidence review-process Impact of the first five years of a national aortic aneurysm screen ng programme Jacomell et al 2016 hccps; / /wuvw uc bi nlmnih Gov/ pubmed/27270466 High quality care for all, now and for future generations key they

Each local AAA screening programme coordinates screening for their population. GP Practices are contacted to notify them of men due to be invited to screening and to inform them that men over the age of 65 who have not been screened can contact the service and self-refer. Promotional materials are also provided to each GP practices for staff, display in public areas to promote awareness and accessibility to the screening programme. GPs are sent result letters to highlight men who have not attended and are requested to encourage self-referral to the programme. Screening programme staff have attended GP forums, provided promotional events in public venues such as Sainsbury supermarkets to improve awareness of men aged 64 and over and the wider public. In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men's awareness of their options to attend screening: A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme: This is monitored by commissioners and informs screening programme communication strategies with the local population: In 2018-19 this will include: Targeted work with GPs in areas of higher deprivation and potential inequalities in access Working with other health providers to 'sign post' men aged 64 and older to the programme Promotional media campaigns for GP surgeries/Pharmacies/Public Arenas Community events Working with patient groups and advocates social media advertising and development of programme website Thank you for bringing your concerns to my attention: hope this response provides you with the assurance that NHS England is responding to the concerns raised and has taken appropriate action: