Samuel Garner

• 

Department 
of Health & 
Social Care 

YourRef:­
Our Ref: 

Ms Alison Patricia Mutch 
HM Senior Coroner, Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1  3AG 

From Edward Argar MP 
Minister of State for Health 

39 Victoria Street 
London 
SW1H0EU

020 7210 4850 

2~ ~ 

September 2020 

Thank you for your letter of 27 July 2020 to Matt Hancock about the death of Samuel 
Gamer.  I am responding as Minister with portfolio responsibility for. NHS operational 
performance, including emergency care and winter planning. 

Firstly, I would like to offer my sincere condolences to Mr Gamer's family and loved ones. 
I was very sorry to read the findings of your investigation into Mr Gamer's death, and 
specifically the poor standard of care that Mr Gamer experienced at the emergency 
department at Stepping Hill Hospital, Stockport.  That Mr Gamer experienced significant 
delay to being admitted to a hospital bed and received treatment in a corridor is 
unacceptable and falls short of the high standards of care we expect from the NHS and 
that the NHS strives so hard to deliver. 

We must do all we can to learn from what happened to Mr Gamer and improve the safety 
and quality of NHS care and I expect the Stockport NHS Foundation Trust and its local 
system partners to reflect carefully on the findings of your investigation. 

My officials have made enquiries with the Care Quality Commission (CQC), the 
independent regulator of quality, and NHS England and NHS Improvement (NHSEI) and I 
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 Gamer'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 1• 

1 https://www.cgc.orq.uk/provider/RWJ 

 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. 

I 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 
Gamer's death.  My officials have brought the concerns in your report to the attention of 
NHSEI and the CQC. 

I 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. 
I would like to explain the national level action we are taking to support the NHS 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. 

2 https://www.england.nhs.uk/urgent-emerqency-care/nhs-111/next-steps-for-nhs-111 / 

3  https://www.lonqtermplan.nhs.uk/ 

 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. 

We know that adult 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. 

It is 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.Sbillion 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. 

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

~~--•  l ,
7 ~~ 

EDWARD ARGAR MP

Greater Manchester  Health and Social Care Partnership 
By Email 

E: 

12 November 2020 

Ref:  

Ms A Mutch OBE 
HM Senior  Coroner 
Coroner’s  Court 
1 Mount Tabor  Street 
Stockport 
SK1 3AG   

Dear Ms Mutch  

Re: Regulation  28 Report to Prevent Future Deaths – Samuel  Garner, date of 
death: 19th October 2019 

Thank you for your Regulation  28 Report concerning  the death of Samuel Garner on 
19th October 2019.  Firstly, I would  like to express  my deep condolences  to Mr 
Garner’s  family.  

The regulation  28 report concludes  Samuel Garner’s  death was a result  of 1a) 
Bronchopneumonia;  1b) Traumatic pneumohaemothorax;  1c) Right rib fracture; and 
II) Vascular  dementia,  Frailty. 

Following  the inquest  you raised  concerns in your Regulation  28 Report  to NHS 
England  regarding:   

1.  The inquest  heard evidence that on admission  to Stepping  Hill Hospital  the 

Emergency Department  was extremely busy due  to the volume of patients  in the 
department.  This  had been typical of the picture in both the preceding  and 
following  weeks due to winter pressures/demands. 

2.  As a result  of the lack of appropriate  space Mr Garner an elderly and vulnerable 
patient  was treated  in the corridor for periods  during  his stay in the ED. This 
included  whilst  he was being  given antibiotics  intravenously  - he scored on the 
sepsis  pathway on arrival. He was also  moved in and out of bays depending  on 
varying prioritisation  of need. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  He waited  a number of hours  for his  chest to be drained  (after it was identified 

that was what was required)  due to competing demands  on clinical staff. He was 
in significant  distress  whilst waiting. 

4. 

It was identified  at an early stage  that he would need  a surgical  bed and his  care 
would be optimised  in such a setting.  There  was a significant  delay in moving 
him from the Emergency Department to a surgical  ward due to lack of bed 
capacity within  the Trust. 

 I have responded  to each of your individual  points  below. 

Point 1 high levels  of demand  and Emergency  Department capacity 

The national  and local pressures  on the urgent  and emergency care system have 
been  well pubilicised  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 hosptial  beds  and therefore 
crowding and delays  within Emergency Departments.   

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

•    To reduce attendances  to Emergency Departments  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:  

o  Ambulance attendances  by 100 per day across GM 
o  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.  

 
 
 
 
 
 
 
 
 
 
 
 
 I can confirm that all localities  within  GM have now gone  live during the last  3 weeks 
with their services.  A new national  campaign to promote 111 First  will be launched  in 
early December which will encourage  patients  to call 111 before deciding  to attend 
an emergency department.   

It is also worth noting  that GMHSCP also  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 2 – Corridor care within the emergency  department 

As highlighted  above,  crowding within emergency departments  results  in patients 
having to be cared for in non-designated  areas within  the department.  This  can 
include  corridor spaces.  This is not something  that  is supported  but, is often the 
result  of both high levels  of attendances  and reduced flow out of the emergency 
department.   The work described  in points  1 and 4 of this  response  will help to 
reduce the risk of crowding and  therefore corridor care.  

It should  be noted that  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 help  mitigate  some of the risks associated  with 
corridor care.  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.   

Point 3 – delay in completing  a chest  drain  

It is not possible  for the GMHSCP to comment on this specific aspect  of care. I have 
contacted Stockport NHS Foundation  Trust and I have been  advised  as follows: 

Mr Garner sustained  the injury on the 23/09/19  and  he attended  the Emergency 
Department  the following day. He had a NEWS2 score of 0, normal CXR and 
pelvis/R  hip XR and so he was discharged  after FRESH assessment  with safety 
netting  advice. 

He returned  unwell  on 11/10/19  at 1242hrs  with NEWS2=11 (T 35.8, BP 149/77,  HR 
101, RR 32, SaO2 98% (on 12L O2). He had developed  an oxygen requirement  with 
shortness  of breath.  He had been  at home with daughter  and  son-in-law  with carers 
4X/day but had been  in respite  for the previous  2/52.  He had apparently  lost  18kg in 
weight  and had had abdominal  pain.  He had required  a buprenorphine  patch for pain 

 
 
 
 
 
 
 
 
 
 
 relief. His blood  gas showed  pO2 of only 15.2 on 12L oxygen. 2 consultants  were 
involved in his care in rapid assessment  and seen  by an FY1 at 1417hrs.  He had IV 
antibiotics  and fluids prescribed  and  a chest x-ray was requested  at 1352hrs  which 
was performed at 1608hrs. 

The x-ray  showed  a moderate  to large  right-sided  hydropneumothorax  on review by 
a middle-grade  doctor with the attending  FY1. The chest injury protocol would 
suggest  a CT scan at this point  for further imaging,  and also  to further investigate  the 
nature  of the fluid in the pleural  cavity, particularly  18 days after the injury.  The CT 
thorax, abdomen  and pelvis scan was requested  at 1727hrs,  but there  was a delay 
as the first biochemistry  blood  sample was haemolysed  and so had to be repeated. 
The eGFR must be known by the radiologist  before they authorise  a contrast  CT 
scan due to the theoretical  risk of contrast-induced  nephropathy.  The eGFR result 
went onto the system at 1755hrs  but the CT scan was done at 1918hrs  and  then 
reported  at 2010hrs.  This  showed  it to be a likely haemothorax  with almost  complete 
collapse/consolidation  of the underlying  lung.  There were slightly  displaced  fractures 
of right 10th-12th  ribs with fractures in 2 places on the 10th and  11th ribs 
radiologically.  This  is not clinically so significant as the 11th  and 12th ribs  are floating 
and so the fact that these  lower ribs may not move in a co-ordinated  fashion,  it would 
not really affect ventilation.  The important feature was the massive haemothorax,  but 
as it was 18 days old he was discussed  with cardiothoracics  in Wythenshawe.  They 
suggested  a chest drain and  local admission  under  the general  surgeons.  The 
patient  had been  handed  over by the FY1 doctor to an ST1 doctor. The ST1 doctor 
has long  since rotated  on but records suggest  that she asked the surgical  registrar  to 
insert  the chest drain,  but then a middle  grade documents  that by 2210hrs  he had 
inserted  a chest drain  and 1200ml blood  had drained  out.  The check CXR was done 
at 2225hrs  that shows  it to be in place. 

Therefore, the decision  to insert  the chest drain  was made at 2030hrs  when the ST1 
documents  the advice from cardiothoracics.  The drain  had been  inserted  no more 
than 100  minutes later.  Mr Garner was moved  from cubicle 13 to resus  bed 2 at 
2054hrs  which would imply no actual delay,  as he needed  to be in the right place 
and such a procedure requires  equipment  and personnel  to be assembled,  and  then 
the procedure  takes some time. The attending  doctor records it to have been  an 
uncomplicated  procedure.  Oramorph was given at 1823hrs  and  IV paracetamol  after 
the drain  was inserted,  and often significant  amounts of analgesia  are necessary  to 
facilitate the drain  insertion,  but that was not required.  There  are multiple  nursing 
entries  that do not suggest  him to be in pain or discomfort. His oxygen requirement 
improved dramatically after the drain. 

 It was a complicated journey  to the drain  being  inserted  , as the requirement  for it 
was not apparent  until  he had been  seen by the FY1. The delays  were due to clinical 
need;  the haemolysed  bloods  delayed  the CT and a further delay to ensure  Mr 
Garner was in the right place for the drain to be inserted.   

Point 4 – 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 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.   Whilst  we 
saw some initial  improvments from this  work, the second COVID wave is adding 
further pressure  on acute hospital  beds due  to increased  admissions  and reduced 
bed availability  as a result  of infection, prevention  control and staffing issues.  Further 
work is underway to review community-based  capacity to support  discharges  and to 
review elective care activity within hospitals.  Reducing or suspending  elective care 
work will help to provide additional  capacity for patients,  such as Samuel Garner, 
who have urgent  care needs. 

I hope  this response  is satisfactory and provides  sufficient assurance  on the work we 
have undertaken  to help mitigate  the risk of future deaths. 

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

Yours sincerely 

Dr 
Chair of GM Medical Executive, GMHSCP