Derek Weaver

[o&* tee th

abe

Guy’s and St Thomas’

NHS Foundation Trust

Dr lan Abbs

Chief Executive

St Thomas’ Hospital
Westminster Bridge Road
London

SE1 7EH

Dr Andrew Harris

Senior Coroner for inner London South
Southwark Coroner’s Court

1 Tennis Street

London

SE1 1YD

Dear Dr Harris,

Inquest touching the death of Derek Weaver

| am writing on behalf of Guy's and St Thomas’ NHS Foundation Trust (the Trust) in
response to the Regulation 28 Report to Prevent Future Deaths (PFD Report) dated
16 October 2019 following Mr Weaver's inquest on 3 October 2019.

In the PFD Report, you expressed the matter of concern as follows:

A consultant thoracic surgeon who was involved in his care after transfer said that he
had a higher chance of death because surgery was at a time of SIRS. If he had been
transferred earlier he would have had surgery when he was not septic. It would have
been two stages: the first being key-hole surgery, with mortality of only 1 in 100. That
may have obviated the necessity of second stage decortication surgery with mortality
of 5%, but it was probably needed anyway. The delay in transfer related to a surge in
referrals, limiting capacity. Most regional referrals of this sort needed to be treated at
weekends to maintain treatment of cancer cases in the week. There had been
pressure fo secure greater resources. The risk of potentially preventable deaths will
recur whenever there is such a surge in referrals and be mitigated by the provision of
more beds.

The Trust response to the matter of concern

Thank you for giving the Trust the opportunity to respond to the concern raised in the
PFD Report. The Board and | take this issue particularly seriously and am sorry that
this issue may have contributed to Mr Weaver's death. Set out below is the context of
our Thoracic Surgery Service and the improvements that we have implemented to
mitigate any future risk.

The Trust’s Thoracic Surgery Unit

The Thoracic Surgery Unit at Guy’s Hospital is one of the largest in England both by
consultant numbers (currently 6) and activity. It currently performs over 1500 cases a
year, approximately 600 lung cancer resections per annum (representing almost 9%
of all cases in England and Wales) and provides advice to other hospitals within a
large geographical area (South East London, Berkshire, Kent and a large part of East
Sussex) for patients potentially requiring non-elective and emergency thoracic surgery
intervention. A significant number of patients (approximately 200 / year) are referred
as emergencies or for consideration of in-patient transfer, if their clinical condition
requires urgent intervention. Pressure on beds, and to a lesser degree, theatre
capacity in relationship to increased activity year on year, has meant that it is not
uncommon for patients to wait for several days to transfer in if they are clinically stable.
At certain times of the year when influenza and bacterial pneumonias are endemic,
the number of referrals will often increase and these patients are often septic and
unwell.

The management of transfers in May 2018

At the time of Mr Weaver's death in May 2018 the Thoracic Surgery Service operated
a “consultant of the day” system. Each day the duty consultant was responsible for
reviewing all new referrals and patients already accepted to determine urgency and
priority for available beds. The Service required all referral requests to be made by
email using the secure NHS mail system so that an electronic record of discussions
was available to staff. It was usual practice to advise referrers to update the Unit if
there was a clinical deterioration.

At this time the Thoracic Surgery Service also managed their own bed allocation,
including beds for elective activity, tertiary referrals and urgent transfers.

The management of transfers in December 2019

In April 2019, to improve the Thoracic Surgery Service, the referrals system was
changed to a “consultant of the week” system. A single consultant and their team take
responsibility for the triage and management of all referrals for the week, with the aim
of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service.
The “consultant of the week” system will be audited to ascertain whether it has
improved the management of transfers in.

In October 2019, to mitigate the risk of capacity issues impacting on transfers, the
Directorate Management Team transferred the management of the Thoracic Surgery
Service's beds and urgent transfer process to the Site Management Team. This
change aligned the Thoracic Surgery Service with other services across the Trust.
The process, set out in the UTCI Fiow Chart (appendix 1), enables the Thoracic
Surgery Service to triage its patients into three categories (1) Admission not urgent,
(2) Urgent — Needs admission within 48 hours and (3) Urgent — Needs admission
immediately and for the appropriate transfer to be arranged.

When a patient is identified as ‘Urgent — Needs admission within 48 hours’, the Adult
Urgent TCI Request Form (appendix 2) is completed, sent to the relevant Site Nurse

Practitioner (SNP) Team. The patient’s details are then added onto an Excel
spreadsheet, which is a live document. Once a bed is available, the SNP will contact
the patient either at home or via the staff at the relevant healthcare provider to arrange
admission and the patient is transferred in.

This process enables the central SNP team to respond to demand appropriately and
to have oversight of current waiting lists. If bed pressures increase in Thoracic Surgery
Services, the SNP team, which has an overview of all available beds on the Guy’s site,
can proactively move suitable patients to alternative beds at Guys’ Hospital to facilitate
more transfers in to the specialist service.

The Trust is looking towards an electronic referral system that allows local specialist
services to manage their own tertiary referrals and gives the Site Management Team
an overview of the current waiting list. In addition, the Trust Operational Board is
currently looking to increase the number of beds on the Guy's Hospital site for Thoracic
Surgery patients. This will be achieved through switching the wards on which services
are provided and undertaking the necessary estate works. It is expected that the
increased capacity will be available during the first quarter of 2020.

Yours Sincerely
Tan. Peley

Dr lan Abbs
Chief Executive & Chief Medical Officer
Guy’s and St Thomas’ NHS Foundation Trust

Mrs Celia Ingham Clark
Medical Director for
Professional Leadership and Clinical Effectiveness

Mr Andrew Harris Skipton House
HM Senior Coroner 80 London Road
Inner South District Greater LONDON SE1 6LH
London

Southwark Coroner's Court
1 Tennis Street

Southwark

SE1 1YD

6" March 2020

By Email to [a

Dear Mr Harris,

Re: Regulation 28 Report to Prevent Future Deaths — Derek Weaver (date of
death 31/05/2018)

Thank you for your Regulation 28 Report (hereafter “the report”) dated 16 November
2019 concerning the death of Mr Derek Weaver on 31 May 2018. _ Firstly, | would
like to express my deep condolences to Mr Weaver's family.

ia
:

The report concludes Derek Weaver's death was as a result of natural causes but
was contributed to by a 14 day delay in transfer for surgery which was related to
exceptional pressures on bed capacity.

Following the inquest you raised concerns in the report to NHS England regarding
surgery occurring at a time when the patient was septic. If the surgery had
happened earlier when he was not septic, the procedures which would have been
used have a lower mortality probability. As you identified the delays in referral and
treatment were related to a surge in referrals at the time, which unfortunately limited
capacity. As a result you consider that the risk of potentially preventable deaths will
reoccur in the future whenever there is such a surge and could be mitigated by an
increase in bed capacity.

In relation to the specific question on capacity to transfer a patient from a District
General Hospital to the Guys and St Thomas Trust (GSTT) cancer centre, | can
confirm that there have been several regional assurance activities in relation to the
quality and safety of thoracic services in London. The National Specialised
Commissioning Quality Surveillance Team (QST) undertook peer review visits for
Lung services in 2017.

Continue..../..2

Please note no immediate risks were identified in the service at GSTT following this
review. Furthermore, later assessments in 2018/19 by the QST team and through
our annual surveillance exercise also did not identify any ongoing serious quality or
safety concerns at GSTT. Although not specific to assessing the overall bed balance
and its appropriateness the review did look at pathways and patient flow, that is,
from a district general hospital to a specialist (tertiary) care hospital. However, that
being said we would recognise that currently GSTT is not meeting national targets
for the 62-day cancer target and this failure is subject to oversight by commissioners
with an action plan designed to ensure compliance.

Within London we do have other thoracic providers (eg. University College Hospitals
and Imperial Hospitals amongst others) so there is the possibility to change the
thoracic surgery pathway for both lung cancer patients and patients with conditions
such as empyema that require urgent surgery too, if we felt insufficient progress
was being made on meeting the nationally set response standards. We can confirm
we will keep this under review as we recognise the importance of making sure that
all patients needing thoracic surgery can get quick access to high quality services.

With the new national pilots to identify lung cancer at an earlier stage we recognise
that we will need to review capacity and ensure that we have sufficient critical

care beds to support what we know will be more patients accessing treatment. We
will be actioning this in the light of new policy and due to the concerns raised by
yourself as a result of Mr Weaver's death.

We have attached as an Appendix a short description of assurance processes that
have taken place over the past two years and their findings.

Thank you for bringing this important patient safety issue to my attention and please
do not hesitate to contact me should you need any further information.

Yours sincerely,

Celia Ingham Clark
Medical Director for Professional Leadership and Clinical Effectiveness
NHS England and NHS Improvement

]

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|

Boa From Nadine Dorries MP

Department eee aeeen ee icide Prevention and Mental Healt
of Health & 39 Victoria Street
Social Care SWIHOEU

020 7210 4850

Your Ref: 01562-2018
Our Ref: PFD-1194553

Dr Andrew Harris

HM Senior Coroner, London Inner South
HM Coroners Court

1 Tennis Street

Southwark

London SE1 1YD

Thank you for your letter of 16 October 2019 to Matt Hancock about the death of Mr Derek
Weaver. | am replying as Minister with responsibility for patient safety and | apologise for
the delay in replying.

lhe March 2020

Firstly, | would like to say how saddened | was to read the circumstances of Mr Weaver's
death and | extend my sympathies to his family and loved ones.

We must do all we can to ensure that the NHS provides high-quality, safe services and
taking the learnings from incidents, such as the sad death of Mr Weaver, is key to ensure
necessary improvements are made and future deaths are prevented.

Departmental officials have worked with NHS England and NHS Improvement (NHSE]),
which is responding separately to your report, to prepare this response.

| am advised that NHS England’s national Specialised Commissioning Quality Team has
undertaken peer review and surveillance activities of thoracic services in London, including
at the Guy’s and St Thomas's NHS Foundation Trust where no serious quality or safety
concerns were identified. | am further advised that NHSEI will maintain oversight to
ensure patients requiring thoracic surgery can access the service in a timely way,
according to their clinical condition. This will include reviews of bed capacity in response
to the ambition set out in the NHS Long Term Plan, for earlier and faster diagnosis of
cancer’ and the impact this might have on related services such as critical care beds.

| am aware that the Guys and St Thomas’ NHS Foundation Trust has responded to your
report with information on the measures it has taken to improve the triage and
management of patient transfers and referrals so that they are clinically prioritised. | also

‘ https://www.england.nhs.uk/cancer/strategy/

understand that the Trust is looking to increase the bed capacity of its Thoracic Surgery
Unit to better meet the needs of patients.

Finally, | note from your report that it iook several months to receive medical records and
other material from the East Sussex Healthcare NHS Trust. While | do not know the
circumstances in this case, | want to provide assurance that NHS trusts have a legal duty
of candour? to act in an open and honest way when there are investigations into the death
of a patient in their care, as well as legal duties to provide all relevant information to
support coronial processes. This was reinforced in a communication by NHS
Improvement to NHS trusts in 20163.

| hope this response is helpful. Thank you for bringing these concerns to my attention.

Redes:

NADINE DORRIES

3 https://improvement.nhs.uk/re ies-relating-coroner-inquests/