Stanley Oliver

From Ben Gummer MP
Parliamentary Under Secretary of State for Care Quality

De partm ent Richmond House

of Health 79 Whitehall

SW1A 2NS

POCS 948085 Tel: 020 7210 4850
Mr A-gWalsh 03 SEP 2015

Area Coroner

Coroner’s Office

First Floor, Paderborn House
Howell Croft North

LA mae

BLI 1QY

Thank you for your letter of 16" 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 (GD)
Radiologists out of hours (ooh) at the Salford Royal Hospital (SRH) NHS Foundation
Trust and the lack of any ooh rotas to ensure that crucial procedures can be carried out
on patients ooh and at week-ends.

I note that your letter has been sent to the SRH Trust and I 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 ooh GI radiologists to perform crucial procedures;

e provision of ooh rotas within a single Hospital Trust or within a group of
Hospital Trusts;

e provision of procedures and protocols to ensure availability of ooh GI
Radiologists ; and,

e related training of health professionals in any such procedures and protocols
that are established.

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 your 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 days a week. Whilst I 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 day
access to IR in the most effective way and a 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.uk/ourwork/qual-clin-lead/7-day-week/
http://www.england.nhs.uk/wp-content/uploads/20 1 3/12/clinical-standards|.pdf

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 days a 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 they 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 being 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 tomorrow.

HEE is currently working with key 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 taking 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 gather 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 post 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 posts that were established as part of HEE’s expansion in the specialty.

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:

www. hee.nhs.uk/work-programmes/workforce-plannin

I am grateful to yqu for/oringing the circumstances of Mr Oliver’s death to my
attention and hopg thay you find this reply helpful.

BEN GUMMER

Salford Royal

NHS Foundation Trust

University Teaching Trust

safe e clean e personal

CHIEF EXECUTIVE
Sir David Dalton

Telephone: 0161206 5186
Email:

4" September 2015
STRICTLY PRIVATE AND CONFIDENTIAL

Mr. A P Walsh

HM Area Coroner

Coroner Area of Manchester West
Ground Floor

Paderborn House

Howell Croft North

Bolton

BL1 1JW

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 16" 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" July 2015 into the events surrounding the death of
Mr Stanley Oliver.

Your letter requested a review of:

e The availability of Gastro Intestinal (Gl) 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 a
group of hospital Trusts.

e The provision of an out of hours rota as referred to above within SRFT.

e 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 drains/stents, 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 7 day IR is a national challenge. A
recent survey (1) shows that not all patients have seven day 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 days a year.

The emphasis of the RCR paper is to encourage Trusts to:

e Put patient safety first, recognising the essential role of interventional radiology in the
provision of modern medical care

e Recognise the resources and manpower required to provide an interventional
radiology service

e Be clear and transparent regarding the local provision of interventional radiology
services

e Decide what is, and what is not possible to provide in and out of hours

e 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 a day, seven days a
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 a national workforce skills gap recognised by

Government with Consultant Clinical Radiologists being 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
daytime/normal 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 ietter 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 a 1 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

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 a comprehensive out of hours IR service. We recognise
our role in making sure that access to IR is equitable across 7 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 very seriously and as a result have developed robust short and medium term
plans to improve OOH access to IR.

Yours sincerely

Aecitatol

Sir David Dalto

CHIEF EXECUTIVE

cc
Edmund Oliver, Mr Oliver's son.
Geoffrey Oliver Mr Oliver's son

Jeremy Hunt MP, Secretary of State for Health