Dear Dr Wilcox; Thank you for raising the issues arising the invectigation and Falvo. am responding on behalf ofl inquest into the death of Ms You raised matters Of Medical Director for London and concern: (1) The A&E departments have insufficient cover to ensure that have able to secure airways via emergency tracheotomy: on site clinicians (2) That the planned and provided to those expected to including the use as appropriate of surgical tracheotomea manage and secure airways that those clinicians have both the skills and is reviewed and upgraded such an emergency situation. confidence to perform such procedures in First let me express regret at this sad death and share your wish reduce the risks of such a tragedy recurring: that lessens can be learnt to There iare l insufficient experienced ENT surgeons to provide immediately cover in+all A&E departments at all times, and to do so would be available resident responsible for the provision of A&E services are expected to impractical. Acute Trusts ensuring that general training s availableco tneeinitaececeivngcoanise ARd,radagathsserkby expertise can be accessed in timely staff in A&E and that specialist Trauma Life way; A&E_ senior staff are trained as part of Advanced Support (ATLS) in both tracheotomies and needle crichothyroidotomy: repeated at least four years to ensure skills and confidence This is are maintained, Across London there has been a review of Emergency Departments senior staff with these skills as part of a wider review of and the availability of clear that provision has varied, and standard has Quality Standards in Acute Trusts. It is have consultants on site 24/7 and all A&Es been agreed so that Major Trauma units hours with senior training doctors (ST4s) will have increased consultant presence over 16 substantial challenge on site and available for the other time: This is as there is shortage of A&E doctors, but already made strides to meet these standards and this also been a drive Trusts have of some A&Es. behind the reconfiguration from two they training every many has

The Urgent and Emergency Care review, currently led by is expected to lead to the development and designation of Emergency Centres and Major Emergency Centres and ensuring that clear standards and robust plans are in place to deal with this and similar emergencies will be an important component of this development The first stage report was published in November 2013 and further information is expected over the summer: Whilst the circumstances are unusual, we know that an emergency surgical airway will be required from time to time (perhaps once every 3-5 years in typical A&E Department): Training in this procedure is already given to all those who provide advanced airway interventions in an emergency: This includes doctors specialising in A&E, anaesthesia and intensive care Relevant guidelines are disseminated by the Difficult Airway Society and are widely taught and followed; with practical training using manikins and animal models (for example sheep iarynx) , during Advanced Life Support" courses. Because this is a Very rarely performed procedure it is approached with trepidation by some However , figures from the 4th National Airway Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, completed in 2011 on behalf of the Fourth National Audit Project: Royal College 0i Anaesthetists, London, March 2011] indicate that the success rate is generally good when a surgical approach is used, as in this case_ Itis clear that Ms Falvo presented more substantial challenges than other patients, with scarring and obstruction that made intervention much more complex than in is expected in these already very uncommon occurrences; Nonetheless the review and implementation of increased senior doctor in A&Es and the National Review of Urgent and Emergency Care will substantially reduce the risks of this tragedy recurring: