John Cheetham

Greater Manchester Health & Social 
Care Partnership 

4th Floor 
3 Piccadilly Place 
London Road 
Manchester M1 3BN 

Telephone No: 

Email address: 

@nhs.net   

Ms Alison Mutch OBE 
HM Senior Coroner 

By email 
Ref: 1629209 
28 August 2020  

Dear Ms Mutch  

I would like to advise you that Dr 
Health and Social Care Partnership which is why I am responding to your concerns 
in his stead.   

 has left the Greater Manchester 

I am writing in response to the Regulation 28 report you issued on the 13th July 2020, 
following the inquest into the death of John Cheetham at Stockport Hospital. 

You raised a number of concerns and requested a response to confirm actions taken 
and any further proposed actions. I have responded to each of your individual points 
below.  

Points 1 and 2 – high levels of demand and Emergency Department capacity 

The national and local pressures on the urgent and emergency care system have been 
well  publicised  during  the  course  of  the  last  year,  with  Greater  Manchester 
experiencing  significantly  higher  levels  of  attendances  during  the  winter  months. 
Attendances were, on average, 9% higher than the previous year which is about an 
extra 9000 attendances per month across Greater Manchester. This also resulted in 
a higher number of patients requiring admission to acute hospital beds and therefore 
crowding and delays within Emergency Departments.  

As  a  result  of  this,  the  Greater  Manchester  Urgent  and  Emergency  Care  (UEC) 
Transformation Board agreed a revised transformation plan in early January this year 
with two principle ambitions: 

 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 •  To reduce attendances to Emergency Departments (ED) by improving access 
to,  and  utilisation  of,  primary  and  community-based  services  by  rapidly 
developing and testing a GM ‘UEC by Appointment’ model 

•  By April 2022, we will reduce:  

•  Ambulance attendances by 100 per day across GM 
•  ED walk in attendances by 300 per day across GM 

The onset of the COVID 19 crisis delayed the transformation programme until more 
recently where we have refreshed our planning work and agreed to rapidly implement 
new models of care during September and October this year (ahead of winter). The 
new approach will incorporate two elements: 

• 

• 

Implementation of the new national NHS 111 First Initiative, which will ask 
patients to call 111 prior to attending an Emergency Department 
A new pre-Emergency Department triage and streaming system 

Both of these will help ensure patients are streamed or referred to the most appropriate 
service for their needs. This will include a wide range of community and acute-based 
services and will ensure only patients who need an Emergency Department go to an 
Emergency Department. A large proportion of patients will receive early local clinical 
assessment prior to being referred which will help ensure safety. We estimate that the 
new models of care will reduce Emergency Department attendances by around 900 
per day across Greater Manchester.  

It is also worth noting that GMHSCP has a Greater Manchester Urgent and Emergency 
Care Operational Hub, which is designed to provide real time support to local systems 
by monitoring and managing patient flow. The hub has a near to real time data feed 
from all acute hospital sites, which it uses to support decision making around deflection 
of ambulances to alternative destinations when a hospital emergency department is 
showing signs of pressure. The hub also supports the management of discharges from 
hospital and repatriations between hospital sites (in and out of the GM area). The hub 
is under constant development and is working closely with systems to develop more 
sophisticated  methods  of  managing  demand  to  reduce  the  likelihood  of  emergency 
department  crowding  even  further  and  proactively  managing  flow  to  prevent 
blockages.    

Point 3 – hospital bed capacity and the discharge of patients 

As  part  of  the  initial  COVID  19  response,  Greater  Manchester  localities  worked  to 
rapidly develop updated Discharge to Assess Pathway Guidance, which were formally 
approved in late April and have now been adopted across all localities within Greater 
Manchester. The purpose of the guidance is to improve the flow of all patients being 
discharged from acute care and to help ensure patients’ needs are assessed in the 
home  or  usual  place  of  residence.  The  guidance  is  also  designed  to  improve 
consistency across organisational and geographical boundaries, thereby minimising 
unnecessary delays for patients. To help improve the consistency and operation of the 
pathways at the interface between different organisations, it has been agreed that the 
following elements of the guidance are required to be implemented by all localities: 

 
 
 Adoption of a single GM Discharge to Assess Referral Form   

•  Triage of discharge to assess referrals within 30mins 
• 

 Adherence  to  the  guidance  for  COVID  19  testing  for  discharge  and  PPE 
requirements  

•  The supply of 2 weeks medication supplies at the point of discharge from an 

• 

acute hospital 
 Operation  of  a  next  day  follow  up  process  following  discharge  (localities  to 
determine how this is delivered) 

The guidance is fully aligned with national policy and guidance and there has been 
significant additional community-based capacity created to support this.  As a result, 
there has been a significant reduction in the proportion of long stay patients and acute 
hospital bed occupancy levels across all Greater Manchester sites. This has helped 
to improve flow from Emergency Departments and therefore helped reduce crowding. 
Bed occupancy is currently on average 83% across Greater Manchester, which is at 
least 10% lower than the same period last year.  

Point 4- nursing workforce 

Nurse recruitment and retention is a priority for the Greater Manchester system and 
work  is  underway  with  Greater  Manchester  service  colleagues,  NHSE/I  and  Health 
Education England, in order to maximise opportunities for improved nurse staffing in 
all  localities.    The  GMHSCP  executive  workforce  lead  is  planning  to  meet  with  the 
Stockport Trust HR lead over the next month and will agree any further support that is 
required.  

I am also aware that Stockport Trust have recently recruited 30 nurses following an 
overseas recruitment exercise. These staff will be used to improve ward staffing levels 
which will also have a positive impact in terms of ongoing care and flow of patients. 
The  national  Emergency  Care  Intensive  Support  Team  (ECIST)  have  also  recently 
completed  a  review  of  Emergency  Department  Staffing  and  agreed  a  plan  with  the 
trust to make improvements ahead of winter.  

Point 5 – risk assessment of patients in the Emergency Department 

Ensuring patient safety and quality of care in Emergency Departments, particularly in 
times of increased pressure, is highly important in Greater Manchester. All of the acute 
trusts in Greater Manchester now utilise a patient safety checklist in their Emergency 
Departments. These checklists are time-based frameworks that outline clinical tasks 
that need completing for each patient in the first hours of their admittance to an ED. It 
ensures that assessments and tests happen in a timely way in order to improve patient 
satisfaction and reduce risks. These have been adopted from the national checklist 
template which was published in 2017 and which has been proven to improve clinical 
processes  and  reduce  harm  and  serious  incidents  from  unrecognised  patient 
deterioration.  In  addition  to  this,  clinical  leads  from  Clinical  Commissioning  Groups 

 
 
 
 (CCGs) in Greater Manchester carry out regular walkrounds of their respective acute 
trusts and as part of these, usage of the checklist is monitored. 

I hope this response is satisfactory and provides sufficient assurance on the work we 
have undertaken to help mitigate risks to patients in the future.  

Your sincerely  

Interim Chief Officer, Greater Manchester Health and Social Care Partnership

ae From Edward Argar MP

Departm ent Minister of State for Health
of Health & 39 vidocs Stet
Social Care SWIH OEU

020 7210 4850

Your Ref: 1629209
Our Ref: PFD-1239582

Ms Alison Patricia Mutch

HM Senior Coroner, Manchester South
HM Coroner's Court

1 Mount Tabor Street

Stockport SK1 3AG

Thank you for your letter of 13 July 2020 to Matt Hancock about the death of John
Cheetham. | am responding as Minister with portfolio responsibility for NHS operational
performance, including emergency care and winter planning and | am grateful for the
additional time in which to do so.

ms
28 September 2020

Let me start by offering my sincere condolences to Mr Cheetham’s family and loved ones.
| was very saddened to read about the circumstances of Mr Cheetham’s death. The
length of time Mr Cheetham spent in the emergency department at Stepping Hill Hospital,
Stockport is clearly unacceptable and his fall and the injuries he sustained there, are
deeply regrettable. It is important that we take the learnings from Mr Cheetham’s death to
improve the safety and quality of NHS care.

My officials have made enquiries with the Care Quality Commission (CQC), the
independent regulator of quality, and NHS England and NHS Improvement (NHSEl) and |
am aware that regulatory action was taken by the CQC following an inspection at Stepping
Hill Hospital in January and February this year. The CQC’s inspection looked at urgent
and emergency services, among other services, and identified significant concerns similar
to those identified in your investigation of Mr Cheetham’s death. The CQC found that
people were not always kept safe and were at high risk of avoidable harm during periods
of heavy demand on urgent and emergency care services. Emergency care was
consistently unable to be provided in a timely way; and there were significant issues with
the flow of patients through the emergency department and the Hospital. The report of the
CQC’s inspection is available on its website’.

It is essential that health system partners in Stockport take the necessary action, quickly,

to respond to these findings and improve the safety and quality of urgent and emergency
services in Stockport.

‘ https:/Avww.cqc.org.uk/provider/RWJ

| am advised that following the CQC's inspection, health system partners in Stockport
formed a system improvement board, that has representation from CQC and NHSEI, to
oversee the implementation of an improvement plan to address the concerns identified. |
expect this work to also take into account the findings of your investigation into Mr
Cheetham's death. My officials have brought the concerns in your report to the attention
of NHSEI and the CQC.

| am assured that progress is being closely monitored by the Trust Board and that the
CQC is also monitoring progress and conducted a follow up inspection in August 2020.

{ would like to explain the national level action we are taking to support the NHS to
respond to the year-on-year increase in demand on NHS services and in particular,
alleviate the impact of increased activity in the winter.

In 2019/20, this involved continued work to tackle both the increases in demand in urgent
and emergency care and to ensure patients receive the quality of care they need and
expect in a timely and safe manner. For example, the continued roll out of Urgent
Treatment Centres, offering a consistent service to patients and introducing the ability to
book appointments through NHS 111, as well as initiatives such as Same Day Emergency
Care, to reduce non-elective admissions to hospital.

This year, we have provided an extra £3billion to alleviate the particular challenges
brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale
Hospitals and their surge capacity, as well as the NHS's use of independent sector
hospital capacity.

Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will
provide low complex care digitally and ensure those who need more care can receive it in
the right setting more quickly, rather than waiting in A&E2.

NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a
share of £300million additional capital funding to upgrade their facilities ahead of this
winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks
associated with further outbreaks of Covid-19.

The NHS Long Term Plan3, published in January 2019, is supporting the reform of urgent
and emergency care services to ensure that patients get the care they need quickly,
relieve pressure on A&E departments, and manage winter demand spikes. The NHS Long
Term Plan is supported by an NHS budget increase of £33.9billion in cash terms by
2023/24.

This year we made £1 .3billion funding available via the NHS to support the hospital
discharge process in March. As part of the £3billion funding for winter, an extra
£588million has been confirmed to continue enhanced discharge arrangements over
winter and maintain the safe and timely discharge of patients from hospital.

3 https:/Avww.longtermplan.nhs.uk/

We know that aduit social care capacity can become increasingly pressured over the
winter months and this can have a knock-on effect on NHS hospitals. It is important that
suitable packages of care are available to ensure that patients who are medically fit to be
discharged are able to return home and into their communities. This frees up hospital beds.
and ensures that people who really need hospital care, receive it.

Despite the fact that the NHS is busier than ever before, with hospital admissions rising by
18 per cent from 2009/10, the majority of patients are discharged quickly. Both the NHS
and social care services have been working hard to reduce delays and free up beds.

Itis the responsibility of the NHS and its local partners, including social service
departments, to ensure that no patient remains in a hospital bed for longer than clinically
necessary and that any ongoing care and support can begin promptly. Discharge
arrangements from hospital should start well before a patient is actually ready for
discharge, and the hospital should involve local social services at the earliest opportunity
to plan post-discharge care and avoid delays.

The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be
focused on primary and community care. This includes a national roll-out of support for
care home residents so more people can be looked after where they live. The NHS also
aims to place therapy and social work teams at the beginning of the acute hospital
pathway, setting an expectation that patients will have an agreed clinical care plan within
14 hours of admission, including an expected date of discharge.

In relation to the matter of concern in your report about a shortage of nurses trained to
work in emergency departments, | would like to assure you that ensuring the NHS has the
Staff it needs, especially our nursing staff who are the absolute bedrock of the NHS and
care system, is and will remain, a priority for this Government. That is why we made our
manifesto pledge to deliver 50,000 more nurses in our NHS by 2025, which we will
achieve through a combination of investing in and diversifying our training pipeline, as well
as recruiting and retaining more nurses in the NHS.

In relation to emergency nursing specifically, the Health Education England (HEE)
‘Securing the Workforce strategy’*, confirmed that the emergency department registered
nursing workforce had grown by 17 per cent, from 12,491 to 14,613 WTE between 2012
and 2017. More recent figures show that between March 2019 and March 2020 there was
a 7.2 per cent increase in the number of full-time equivalent nurses working in A&E®.
However, we know that attendances and admissions have continued to rise, as has the
overall complexity of the needs of patients.

* https:/improvement.nhs.uk/documents/1826/Emergency department workforce plan _-

111017 Final.3.pdf

5 Figures published by NHS Digital in its NHS Workforce Statistics publication show the number of full time
equivalent (FTE) nurses reported as having the Area of Work ‘A&E’ at March 2020 was 15,593, an increase
of 7.2 per cent from March 2019. This includes paediatric A+E nurses. https://digital.nhs.uk/data-and-

information/publications/statistical/nhs-workforce-statistics/march-2020. Note the definition used for AGE staff

by HEE is not consistent with the definition used to present changes over the past year.

Emergency Nursing is a post graduate career choice, and while there is no NMC®
mandated post graduate education for nurses who choose to work in emergency
departments, HEE supports post graduate learning through the Workforce Development
and Workforce Transformation Funding and more recently with increased Continuing
Professional Development allocations of £1,000 per registrant over three years.

In addition, HEE has worked with the Royal College of Emergency Medicine to develop an
education and training pathway to credential advanced practitioners alongside masters’
level education and standardise the development pathway for more senior nurses in the
emergency department.

Finally, with regard to fails prevention, the National Institute for Health and Care
Excellence (NICE) has published a clinical! guideline on Falls in older people: assessing
risk and prevention (CG1617) that includes guidance on preventing falls in older people
during a hospital stay. The guideline says:

1.2.2.1 Ensure that aspects of the inpatient environment (including flooring, lighting,
furniture and fittings such as hand holds) that could affect patients' risk of falling are
systematically identified and addressed

This recommendation would apply to wards, toilets and other parts of the hospital. The
guideline recommends that for patients at risk of falling in hospital, an assessment of the
patient’s individual risk factors should be conducted and where necessary, appropriate
intervention put in place. NHS trusts are expected to take account of NICE guidelines
when planning care.

[hope this response is helpful. Thank you for bringing your concerns to my attention.

EDWARD ARGAR MP

§ Nursing and Midwifery Council.
7 hitps://www.nice.org.uk/quidance/cg161