Dear Mr. Walsh Re: Mr: Stanley Oliver (Deceased) Response to Regulation 28: Report to Prevent Future Deaths to Salford Royal NHS Foundation Trust; Thank you for your Regulation 28 letter dated 16th July 2015, which you issued to Salford Royal NHS Foundation Trust ("SRFT") and Mr Jeremy Hunt MP , Secretary of State for Health; following an Inquest held on 6" 2015 into the events surrounding the death of Mr Stanley Oliver. Your letter requested a review of: The availability of Gastro Intestinal (GI) Radiologists out of hours to perform procedures crucial to the management of the patient, including the provision of out of hours rotas either within a single hospital Trust or a rota as between hospitals in group of hospital Trusts The provision of an out of hours rota as referred to above within SRFT . July

The provision of procedures and protocols in relation to the availability of Gi Radiologists out of hours and a definitive line of communication whether it be as between Radiologists or by clinical Consultants direct to GI Radiologists to discuss and arrange a procedure out of hours The training of health professionals in relation to the availability of GI Radiologists out of hours including training in relation to the procedures and protocols established in support of out of hours availability_ Background Interventional Radiology (IR) is an essential service within modern medicine. Non-vascular interventional radiology procedures use image guided techniques to access solid or luminal organs for placement of drainslstents, ablation devices or to obtain biopsy specimens. IR techniques are applicable in most clinical domains, including gastroenterology, acute surgery and urology, and can offer significant improvement in patient outcomes. Achieving an appropriately skilled workforce to deliver day IR is a national challenge. recent survey (1) shows that not all patients have seven access to IR and a number of hospitals depend on informal and ad-hoc arrangements to deal with their out-of-hours emergencies: In the survey 93 out of 156 acute trusts responded. Of the 93, 66% of these were able to provide a formal out of hours rota for nephrostomy cover; the only non-vascular interventional procedure considered in this survey The Royal College of Radiologists (RCR) issued a document in 2008 entitled Standards for providing a 24-hour interventional radiology service (2) which recognises the requirement; for the safety of patients, for acute hospital Trusts to have formal and robust arrangements to ensure provision of an emergency radiology interventional service (vascular and non- vascular) 24/7 , 365 a year: The emphasis of the RCR paper is to encourage Trusts to: Put patient safety first, recognising the essential role of interventional radiology in the provision of modern medical care Recognise the resources and manpower required to provide an interventional radiology service Be clear and transparent regarding the local provision of interventional radiology services Decide what is, and what is not possible to provide in and out of hours Enter into discussions with strategic healthcare authorities, primary care Trusts and other Trusts in the region to make arrangements which ensure robust and coherent regional interventional radiology service provision 24 hours day, seven days week As with many NHS acute provider Trusts across the country, the IR service at SRFT is currently unable to deliver a comprehensive out of hours (OOH) service This risk is recognised on both the Trust's corporate and departmental risk registers (Appendix
1). This problem is due to national workforce skills gap recognised by day days

Government with Consultant Clinical Radiologists added to the approved tier 2 occupation shortage list in April 2015 (3). The development of a robust OOH IR service is part of SRFT's strategy and the formal investigation instigated following this incident has helped identified agreement on the way forward within a reasonable time scale as described in detail below. It is accepted that the vast majority of non-vascular interventional cases presenting OOH can be, with appropriate surgical support and medical management; safely delayed until the next daytimelnormal working session. In the RCR document entitled Provision of Interventional Radiology Services (4), it is recommended that access to intervention for non-vascular cases involving genitourinary or gastrointestinal diseases are provided within 12 hours and 24 hours respectively_ Therefore, the Radiology Directorate at SRFT has agreed that a safe OOH non-vascular interventional radiology service would require a seven day service with provision of sessions on Saturdays and Sundays. More emergent treatments would also be available but this need is rare_ Whilst we acknowledge that your Regulation 28 letter focussed on GI intervention out of hours, we feel that the requirement for all non-vascular radiology interventional procedures must be considered. This response therefore relates to the provision of all non-vascular IR out of hours As a final point;, it is important to understand that this incident is uncommon and requirement for IR OOH has been limited. In the past 12 months we have only performed 12 IR procedures OOH at SRFT. However we recognise that as this service develops demand will increase particularly given proposed reconfiguration of acute surgical across the GM conurbation DEVELOPMENT OF INTERVENTIONAL RADIOLOGY SERVICES AT SALFORD ROYAL NHS FOUNDATION TRUST Short term plan The short term plan is to continue to use the SRFT ad hoc service with additional support from Central Manchester NHS Foundation Trust (CMFT): CMFT plan to have a weekend non-vascular intervention service from October 2015 and have agreed that they will support our service and perform cases that we are not able to safely perform at SRFT at weekends. A Standard Operating Procedure (SOP) has been updated to reflect this change (Appendix
2) and further details can be found in the action plan below Medium term plan The medium term plan is to develop in 6 non-vascular intervention rota at SRFT to ensure that there is 7 day cover at Consultant level by April 2016. This will involve a number of detailed actions which are described further within the action plan below: Whilst this has being

been the aim of SRFT radiology for many years, the difficulties of implementation are highlighted by the risks identified within the action plan Long term plan The issues highlighted by this case reflect a national shortage of Consultant Interventional Radiologists and are not particular to SRFT with no acute provider Trust in Greater Manchester being able to provide comprehensive out of hours IR service_ We recognise our role in making sure that access to IR is equitable across days not just at SRFT but more widely across GM and we will be working with the other acute provider Trusts across Greater Manchester to ensure expertise is shared: The Division of Clinical Support Services & Tertiary Medicine will have operational oversight of the action plan and this forms part of the Division's Risk Register. hope the described actions will provide you with assurance that the Trust takes patient safety issues seriously and as a result have developed robust short and medium term plans to improve OOH access to IR.

From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department Richmond House of Health 79 Whitehall London SWIA 2NS POCS 948085 Tel: 020 7210 4850 Mr A Walsh 0 3 SEP 2015 Area Coroner Coroner' s Office First Floor; Paderborn House Howell Croft North Bolton BLI 1QY Thank you for your letter of I6h July 2015 following the inquest into the death of Stanley Oliver: I was very SOrry to hear of Mr Oliver's death and wish to extend my sincere condolences to his family: Your concerns in this case focus on the unavailability of gastro-intestinal (GI) Radiologists out of hours (ooh) at the Salford Royal Hospital (SRH) NHS Foundation Trust and the lack of any oh rotas to ensure that crucial procedures can be carried out on patients ooh and at week-ends: Inote that your letter has been sent to the SRH Trust and [ would expect the Trust to fully address these concerns. You also reveal that the unavailability of ooh GI Radiologists was identified as a national problem at the inquest where evidence showed that there were very few ooh on call rotas for GI Radiologists in UK hospitals. You have therefore asked that we review and consider the following: - availability of oh GI radiologists to perform crucial procedures; provision of ooh rotas within a single Hospital Trust or within a group of Hospital Trusts; provision of procedures and protocols to ensure availability of ooh GI Radiologists and, related training ofhealth professionals in any such procedures and protocols that are established: Lll

Firstly, I would like to advise that the setting of curricular and standards of training for health professionals is the responsibility of the regulatory bodies In addition, the actual provision of ooh rotas and procedures to ensure availability of radiologists, and the training of staff in such protocols, is a matter for each local NHS Trust. In order to address remaining concern, about the availability of ooh GI Radiologists nationally, my officials have liaised with NHS England and Health Education England (HEE) and can provide the following information: NHS England has advised that both Interventional Radiology (IR) and Gastrointestinal (GI) Radiology are available in UK hospitals. Gastrointestinal Radiology provides examinations for the gastrointestinal tract, plus advanced examinations for swallowing disorders and incontinence: GI radiologists also undertake interventional procedures involving the liver and GI tract such as drainage procedures for abscesses or obstruction of the liver: Interventional Radiology (IR) refers to a range of "techniques which rely on the use radiological image guidance (X-ray fluoroscopy; ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) to investigate disease and target therapy precisely. Most IR treatments are minimally invasive alternatives to open and laparoscopic (keyhole) surgery. The procedure outlined in this case could have been undertaken by either GI or IR radiologists. IR is important as it provides an essential and often life-saving service and patients who need it should be able to access IR safely, seven a week. Whilst [ can confirm that there are far fewer GI than IR radiologists available, there is no centrally collected data on the availability of GI radiologists either in or out of hours. Data that has been collected concerning availability of the service is published in the latest fourth survey of IR provision in English Trusts, carried out in 2014 by NHS Improving Quality. The survey shows that; as yet, not all patients have seven access to IR in the most effective way and number of hospitals depend on informal and ad-hoc arrangements to deal with their out-of-hours emergencies. However; NHS England has been working with the British Society for Interventional Radiology (BSIR) to improve access to interventional radiology across England in recent years. Furthermore, in 2013 ten clinical standards for seven day services were developed by the NHS Services, Seven Days a Week Forum; based on guidance developed by Medical Royal colleges and Specialist Societies. http:/www_england nhs uklourwork/qual-clin-lead/?-day-weekl http: Lwww england nhsuklwp-content/uploads/2043/12/clinical-standardsLpdf your days day

These standards describe the quality of services that patients admitted through urgent and emergency routes should expect on every day of the week. One standard requires that hospital inpatients must have 24 hour access, seven week, to consultant- directed interventions, including interventional radiology, either on-site or through formally agreed networked arrangements with clear protocols. In July 2015, NHS England, Monitor and the Trust Development Authority (TDA) wrote to Trusts asking them to provide information about the extent to which are delivering services in line with four of the clinical standards that are expected to have the most impact on mortality. One of these is Clinical Standard 8, on Consultant- Directed Interventions By the end of September 2015 NHS England aim to have a Trust by Trust picture of whether the requirements of the standard are met which will enable them to offer further support for improvement where needed. HEE was established to help improve the quality of care delivered to patients by ensuring that our future workforce is available in the right numbers with the right skills, values and competencies to meet patient needs today and tomorTow_ HEE is currently working with partners to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests. In particular; HEE will ensure the availability, for example, of sufficient endoscopists to deliver bowel scope screening, while account of the wider diagnostic service. In support of this, HEE is setting up a diagnostics workforce steering group, to be chaired by Professor Liz Hughes, Director of Education and Quality, to provide overarching governance: In June 2014,the Centre for Workforce Intelligence (CfWI) was commissioned by the Department of Health (DH) and HEE to evidence on possible shortage occupations within the healthcare sector in England. A review of the Shortage Occupation List (SOL) was completed by the Migration Advisory Committee (MAC) and in April 2015, radiologists were added to the SOL. The number of posts advertised in any specific year is dependent on the number of trainees successfully completing their training and thereby releasing their National Training Numbers (NTN) and for a new trainee to fill. Reductions in recruitment numbers in a specific year in no way indicate; on their Own; a reduction in the volume of training being commissioned. Over the last two years HEE has increased the number of training places available in radiology and in 2015,212 training posts were advertised across England with a 100 per cent fill rate. Included in this number were 16 new that were established as part of HEE'$ expansion in the specialty. days they being key ~ taking gather post posts

At the last validated stocktake there were 952 clinical radiology trainees in England with a further 61 trainees on a break from training due to maternity leave Or Out of Programme' learning or research experience. With a 5 year programme, 952 would indicate an average output intake of 190, although some delays and extensions to training will lower this average number: This level of training has enabled the consultant radiology workforce to grow by over 70 full time equivalent (fte) posts a year between 2009 and 2013 (from 2278 to 2561 fte): HEE s proposed education and training commissions for 2015/16 are set out in their second national workforce plan for England. A copy can be found at: wwwhee nhs uk/work-programmes workforce-planning Lam grateful to yqu forfringing the circumstances of Mr Oliver 's death to my attention and hope thay iou find this reply helpful. BEN GUMMER