Joseph Cheetham

: From Edward Argar MP

Department Minister of State for Health
of Health & 89 Victoria Set
Social Care SW1H OEU
020 7210 4850

Your Ret:

Ms Alison Patricia Mutch

HM Senior Coroner, South Manchester
HM Coroner's Court

1 Mount Tabor Street

Stockport SK1 3AG

Dm tp oe
Thank you for your letter of 30 September to Matt Hancock about the death of Joseph
Michael Cheetham. | am replying as Minister with responsibility for NHS operational

performance, including emergency care and winter planning and | am grateful for the
additional time in doing so.

rt
+0 December 2020

Firstly, | would like to offer my sincere condolences to Mr Cheetham’s family and loved
ones. | was very saddened to read about the lengthy delay Mr Cheetham experienced at
the Emergency Department at Stepping Hill Hospital, Stockport, and that a package of
care to support his discharge from hospital was not available once Mr Cheetham was
medically ready. This falls short of the high standards of care we expect from the NHS
and that the NHS strives so hard to deliver and it is important that we take the learning
from Mr Cheetham's experience to improve the quality and safety of NHS care.

| am aware that this is the fourth Prevention of Future Deaths (PFD) report you have
issued raising concerns about bed capacity and patient flow at the Stockport NHS
Foundation Trust over the 2019/20 winter period. It is clear that the Trust and its local
system partners must reflect carefully on the findings of your investigation and take the
necessary action, quickly, to improve the safety and quality of urgent and emergency
services in Stockport.

As you will know from my response to previous PFD reports raising these concerns,
regulatory action was taken by the Care Quality Commission (CQC) following an
inspection at Stepping Hill Hospital in January and February 2020. The CQC’s inspection
looked at urgent and emergency services, among other services, and identified significant
concerms 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’.

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

| am assured that progress is being closely monitored by the Trust Board and that the
CQC is also monitoring progress with a follow up inspection conducted in August 2020.
Furthermore, | am informed that the issues at Stockport NHS Foundation Trust have been
escalated within NHSEI national governance structures, including to the Executive Quality
Group (EQG), chaired by Stephen Powis, National Medical Director, and Ruth May, Chief
Nursing Officer, and the Joint Strategic Oversight Group with senior representation from
the CQC. | am advised that progress is regularly monitored.

Ata national level, | would like to explain the 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.

A further £2.7billion will go directly to local NHS systems as part of their block contracts for
the second half of this year.

Other elements of the NHS winter plan for 2020/21 include the expansion of NHS 111 to
support patients who need urgent care advice and direct them to the right service more
quickly, rather than waiting in A&E?.

1 https:/Awww.cgc.org.uk/provider/RWJ
2 https:/Awww.england.nhs.uk/urgent-emergency-care/nhs-111/next-steps-for-nhs-111/

NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a
share of £450million 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. Stepping Hill Hospital, Stockport is being
allocated £3,611,000 of this funding to upgrade its emergency department.

The NHS Long Term Plan?, 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 was 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. We also recognise that
staying in hospital when patients are fit to leave can impact on wellbeing and affect
people’s prospects of regaining the level of health and independence they had before
admission.

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. NHS providers are
expected to begin planning for a person’s discharge at the point of admission, which
should include practical arrangements, care requirements and where the person is being
discharged to. 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.

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

| hope this response is helpful. | am grateful to you for bringing these concerns to my

attention.
= SF] ;

eo A

EDWARD ARGAR MP

Greater Manchester  Health and Social Care Partnership 
By Email 

24 November 2020 

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 – Joseph  Michael 
Cheetham,  date of death: 22 January  2020.   

Thank you for your Regulation  28 Report dated  30 September 2020   concerning  the 
death  of Joseph  Michael Cheetham on 22 January 2020.  Firstly, I would like to 
express  my deep condolences  to Mr Cheetham’s  family.  

The regulation  28 report concludes  Mr Cheetham’s  death  was a result  of  
1a) Hospital  acquired  pneumonia; 1b) Reduced  mobility on a background of left total 
hip replacement  dislocation;  ii) Vascular dementia,  Paroxysmal atrial  fibrillation, 
Aspiration  pneumonia.   

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

Point 1 Transfer of patient to the Emergency  Department  despite GP booking 
direct admission  to ward 

It is recognised  that there  are often cases where patients  are booked directly by a 
GP to a hospital  ward or department  (often a medical assessment  unit).  Due to the 
higher  levels of demand on hospitals,  patients  are often re-directed  to attend  the 
emergency department  due  to a lack of capacity on the wards.  This places  further 
pressure  on often already busy emergency departments  and can lead to extended 
wait times for admission  to the receiving ward.  

As part of the Greater Manchester  Urgent Transformation  Programme, we have 
developed  and  agreed  a set of principles  for all localities  to adopt which will help to 
prevent a re-occurrence of this.  The agreed  principles  are as follows: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1. 

2. 

3. 

All HCP referrals (self-presenting  or by ambulance) are accepted direct by the 
speciality  and only clinically unstable  patients  or those  requiring  a time critical 
intervention  are advised to attend  ED. 
All clinically stable  patients  referred to a speciality are assessed  by that 
speciality  in a designated  assessment  area and not in the ED. 
Same Day Emergency Care (SDEC) is provided across  all major specialities, 
12 hours  a day, Monday – Friday. Weekend SDEC services, if not currently 
operational,  should  be modelled  and developed  to meet demand. 

All localities  within GM are now in the process of implementing  these.  In addition  to 
this,  further work is being  undertaken  to help reduce the numbers  of attendances  to 
emergency departments.  As highlighted  in previous  correspondence,  GM has 
agreed  to a new approach which 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.   

All hospital  trusts  in GM will also be implementing  a new national  data set for 
recording  information which will help to monitor the impact of the agreed  changes 
over the longer  term (the Emergency Care Data Set – ECDS). Trusts  are required  to 
have this fully implemented  by April 2021. 

Stockport have also  confirmed that they have recently submitted  an Outline  Business 
Case which will see a new three  storey capital build  able  to receive referrals direct 
from primary care with an aim to care for 45%  of patients  within  Same Day 
Emergency Care by the end of 2023/24. 

Point 2 – delay in discharge  due to waits for a package  of care 

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  – not in the hospital.  If it is not 

 
 
 
 
 
 
 
 
 
 
 
 possible  to disharge  the patient  to their  usual  place of residence  then they are now 
transferred  to a discharge  to assess  bed within the community. To help reduce 
delays,  and improve the operation  of the pathways,  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.  The 
additional  capacity includes:  reablement  support,  domicillary care and community 
beds.  Further work is underway to review community-based capacity to support 
discharges  to ensure  the correct types of capacity. There has since been  a 
significant  reduction  in delayed transfers  of care across GM from approximately 5% 
to less  than 1%.  

Stockport Trust have also implemented  the following  to help improve discharges: 

• 

• 
• 
• 

An Integrated  Transfer Team that comprises nurses,  ward trackers, mental 
health  practitioner,  Age UK and  a virtual homeless  practitioner. 
A Discharge  to Assess  hub with nursing  and  therapy staff 
A trusted  assessor  care home team  
Extra therapy staff in the Bluebell  Discharge  to Assess  unit  to provide 
enhanced  therapy support  and  to improve flow.  

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

Our ref: 12 October 2020 

BY EMAIL 
Private and Confidential 
· Ms A Mutch OBE 
HM Senior Coroner 
HM Coroner's Office 
1 Mount Tabor Street 
Stockport SK1 3AJ 

Stockport 
NHS Foundation Trust 

Chief 
Executive  
Oak House 
Stepping Hill Hospital 
Poplar Grove 
Hazel Grove 
Stockport 
SK2 7JE 

Tel:   

Dear Ms Mutch 

Re: Inquest in to the death of Mr Joseph Cheetham 

· 

I am writing in relation to the further information you requested at the conclusion of 
the  inquest  touching  on  the  death  of  Mr  Joseph  Cheetham,  which  was  held  on  22 
September  2020.  I  would  like  to  thank you  for  highlighting  your  concerns  and  giving 
the Trust an opportunity to respond. The Associate Medical Director, and Associate 
Nurse  Director  of  the  Medicine  and  Clinical  Support  Business  Group  have 
investigated these matters on my behalf and I can now share with you the following 
information. 

· 

I  understand  from  our  inquest  team,  that  you  requested  further  information  on  two 
points. I have taken each point in turn, and trust this approach is satisfactory to you. 

Steps taken to support meal times 

The  Trust  has  in  place  approved  policies  for  protecting  meal  times.  This  includes 
restricting  visiting,  visual  aids  to  identify  people  who  require  extra  support  and 
minimising  clinical  interactions  during  meal  times.  Patients  are  regularly  reviewed 
using  the  Malnutrition  Universal  Screening  Tool  (MUST)  score  for  nutrition  and 
hydration. We monitor nutrition and hydration through nursing quality metrics and the 
ward  accreditation  scheme.  Trained  volunteers  also  support  patients  with  their 
nutrition  needs  across  the  organisation-.  In  addition,  the  corporate  nursing  team  has 
completed  a  mini  accreditation  for  nutrition  and  hydration  compliance  on  all  the 
inpatient wards across the Trust. This process identified many areas of good practice 
and areas in need of more support and guidance. 

All ward areas have received a dedicated 'seven minutes briefing' session focused on 
patient nutritional standards with key points also being displayed in ward areas. The 
Trust continues to promote an annual malnutrition awareness week aimed at raising 
the  profile  of  the  importance  of  good  nutrition  and  hydration  in  the  Gare  and 
treatment of patients. ·  · 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At a local level on Ward A11, an action plan has been devised in order to highlight 
the  improvement  required  to  deliver  consistent  quality  patient  care  to  the  high 
standards we set for ourselves. These actions include: monitoring completion of the 
MUST  score;  refresher  training  for  staff;  compliance  with  role  specific  training  for 
staff; additional support from dieticians and the Quality Matron; visibility of mealtime 
standards  and  expectations  in  ward  areas;  reinforcing  communication  at  shift 
handover  regarding  patients  with  nutritional  needs;  monitoring  staff  compliance 
through appraisal and audits. 

Guidance on the administering of medication following a SALT assessment 

The  Trust  Speech  and  Language  Team  (SALT)  has  in  place  Trust-wide  approved 
guidance, which has been developed to ensure patients are appropriately assessed 
for swallowing ability including the identification of specific problems occurring during 
the oral and pharyngeal stages of swallowing. 

The  stroke  specialist  nurse  has  led  a  dedicated  project  aimed  at  ·  increasing 
awareness  amongst  clinical  staff  of  the  important  role  of  patient  positioning  in  the 
respect of naso-gastric tubes used for the administration of medication and nutrition. 
This  project  promotes  the  sharing  of  best  practice  guidance  and  associated 
information from SALT via teaching session. 

I  have  enclosed  several  documents  for  your  information  that  detail  best  clinical 
practice which are used across the Trust 

•  Seven minute briefing regarding supported mealtimes 

This briefing document has been shared with all .staff across the Trust. The 
briefing  is  disseminated  to  every  ward  area  in  the  hospital  with  the  aim  to 
highlight  important  factors  and  promote  discussion  within  teams.  It  is 
displayed  in  all  wards  as  a  reminder  of  the  expectation  from  staff  for  our 
patients. 

•  Meal time standards 

These   standards   are · displayed  on the ward information boards, with · 
information for all staff to read in regards to expectations on the ward. During 
the staff safety huddle performed twice daily, all staff are made aware of 
patients with specific dietary requirements and needs, highlighting 'at risk' 
patients. 

•  Green apple card 

The card was introduced as a trial in order for all staff to be aware of which 
relatives  had  been  authorised  to  attend  the  ward  at  mealtimes,  following 
discussion with the senior nursing team. This currently is  on hold due to the 
visiting restrictions due to the pandemic. The rationale behind the card, is to 
ensure  ease  of  access  for  the  relatives  of  patients  identified  as  requiring 
assistance at mealtimes. 

In addition there is also a Trust intranet microsite for Nutrition and Hydration which 
staff can access at any time to find up to date information and guidance to support 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 our' patients.  The site contains information, advice, policies and procedures to 
support and educate staff. 

I trust  that this  answers  the queries  raised  following  the  inquest. 
further queries please do not hesitate to contact me. 

' 

If you have any 

Chief Executive 

Enc 

Page 3 of 3