Shaun Mansell

Ms Murphy, HM Assistant Coroner for  
Stoke-on-Trent & North Staffordshire Coroner's Court 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent 
ST4 1HH 

coroners.office@stoke.gov.uk 

Dear Ms Murphy, 

National Medical Director 
& Interim Chief Executive, NHSI 
Skipton House 
80 London Road 
London 
SE1 6LH 

23 December 2021 

Re: Regulation 28 Report to Prevent Future Deaths – Shaun Mansell, who died 
on 6 July 2021  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 
November 2021 concerning the death of Shaun Mansell on 6 July 2021. Firstly, I 
would like to express my deep condolences to Mr Mansell’s family.  

I note the inquest earlier this year concluded Shaun Mansell’s death was a result of 
natural causes (acute gastrointestinal haemorrhage and liver disease due to chronic 
alcoholism). 

Following the inquest, you raised concerns in your Report to NHS England regarding 
excessive delays in handing over patients at hospital which impacts on ambulances 
getting to patients. 

I can confirm that national policy has set out that handovers should take no more than 
15  minutes,  ensuring  patients  receive  necessary  emergency  care  and  allowing 
ambulances to get back on the road responding to patients in the community.  
We recognise however that hospital handover delays are a significant challenge for 
ambulance services and acute trusts both regionally and nationally and tackling this is 
a high priority for NHS England and NHS Improvement.   

The NHS Long Term Plan made a commitment to work with ambulance services to 
eliminate hospital handover delays. Ambulance services continue to, where 
appropriate and safe to do so, use alternative approaches to taking patients to 
Emergency Departments (EDs) and therefore reduce front door congestion, 
including increasing use of ‘See and Treat’, and conveying patients to non-ED 
settings such as urgent treatment centres.  

Handover delays can be linked to patient flow issues, and NHS England and NHS 
Improvement are also supporting systems to improve hospital flow through reducing 
length of stay and supporting timely discharge.   

NHS England and NHS Improvement 

 On 13 December, as part of “Preparing the NHS for the potential impact of the 
Omicron variant and other winter pressures”,  NHS England and NHS Improvement 
wrote to systems to reiterate earlier communication regarding the need to eliminate 
ambulance handover delays to ensure vehicles and paramedic crews are available 
to respond to urgent 999 calls. A range of measures, which have demonstrated 
benefits in addressing handover delays, were previously shared with all systems. 
I can also confirm that additional funding was made available for winter 2021/22 to 
support investment in Hospital Ambulance Liaison Officer staff to support handover 
of care.  

Thank you for bringing this important patient safety issue to my attention and I do 
hope the above information helps to inform you of the work and steps being taken by 
NHS England and Improvement to tackle it. 

Please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director  
& Interim Chief Executive, NHSI

3 December 2021 

Ms Sarah Murphy 
H M Assistant Coroner 
547 Hartshill Road 
Stoke on Trent 
ST4 6HF 

Dear Ms Murphy 

Royal Stoke University Hospital 
Executive Suite 
Springfield 
Newcastle Road 
Stoke-on-Trent 
Staffordshire 
ST4 6QG 

Inquest Touching the Death of Shaun Mansell 

Thank you for your letter dated 16 November 2021, in relation to the late Shaun Mansell who I note, very sadly, died 
as a result of natural causes at home; I extend my sincere condolences to Mr Mansell’s family.  

Whist  I  am  pleased  to  provide  the  following  response  to  the  concerns  that  you  raised  at  the  inquest  touching  the 
death of Mr Mansell, I need to express how perplexed I was at receiving the Regulation 28 in the first instance, given 
that the University Hospitals of North Midlands NHS Trust (UHNM)  never treated this gentleman; I also understand 
that there was no one from the Trust in attendance at the inquest.  

Nevertheless, you raised the following matter of concern to be addressed by this Trust only: 

1. There were excessive delays in handing over patients at hospital.  The  West Midlands Ambulance Service
Serious Incident Report found that there were excessive handover of patients at the Royal Stoke University
Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance
Service  getting  to  patients.    Oral  evidence  was  given  to  the  effect  that  this  was  a  national  issue,  and  not
limited to the acute trusts within the West Midlands

I understand  that on the night in question, ambulances were delayed at UHNM  as they  were at  most hospitals up 
and down the country, which is something that all of us  in the wider economy  work very hard to avoid. However, I 
cannot  understand  why  UHNM  would  be  singled  out  in  this  way,  in  relation  to  this  incident,  when  the  reason  for 
ambulance delays at hospitals are multifactorial and rely on many system partners and organisations, including the 
ambulance service, to resolve.  For example, delays can occur for the following reasons to name but a few: 

1. The  acute  Trust  (wherever  that  may  be)  has  limited  or  no  bed  capacity  -  this  can  be  because  it  is
overwhelmed by the number of emergency patients and/or because too many beds are full with patients that
do not need to be in hospital and are medically fit for discharge.

It  is  the  responsibility  of  the  Local  Authority  Social  Care  system  and  our  system  Community  providers  to
deliver such ‘out of hospital’ services however, because of their own staffing and capacity constraints they
are  not  able  to  take  new  patients.  Therefore,  both  patients  and  the  incumbent  risks remain  with  the  acute
provider.    The  consequence  of  this  is  lack  of  flow  through  the  hospital  generally  which  then  impacts  on
Emergency  Departments  (ED)  throughout  the  country;  they  become  congested  and  ambulances  have  to
wait to off load new patients.

2. Approximately 30% of patients who attend ED do not need the services of the ED:

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 a. 

 An  increasing  number of these patients arrive  because they cannot get an appointment  with their 
GP because GPs are having their own workforce crisis and do not have the capacity or resource to 
see the ever increasing demand in Primary Care. 

b.  There  is  a  role  for  Public  Health  and  all  health  and  care  providers  to  support  the  population  in 
making  better  and  more  appropriate  choices  for  health  care  such  as  self-care,  NHS  111, 
Pharmacists etc.  Reducing demand in ED by 30% would be significant and would probably resolve 
all flow issues and therefore negate the need for any ambulances to wait unnecessarily.  

c.  A number of patients brought to hospital by ambulance do not need to come to an acute provider. 
There are other services available to prevent a conveyance to hospital and these alternatives, such 
as the Community Rapid Intervention Service (CRIS) and the Local Authority Falls Service, should 
be  used  instead.    This  would  reduce  the  number  of  ambulances  coming  to  ED  and  therefore  the 
waiting times in the ED. As a result of patients attending EDs who do not need to, the department 
becomes congested and again ambulances end up waiting as a result. 

3.  Patients  with  Mental  Health  illnesses  spend  too  long  in  EDs  waiting  for  mental  health  assessments  which 
are provided by our mental health providers.  Again if these patients did not have to wait as long as they did, 
the ED would be less congested and flow of ambulances would be improved. 

Whilst my aim is not minimise the outcome for Mr Mansell in this  particular case, I do hope the above gives a few 
examples of how this is a whole system issue, involving every provider of health and social care.  I also hope from 
the examples provided above you can see why, as just one provider, I was dismayed at receiving the Regulation 28 
when in reality, if a Regulation 28 was to be sent beyond West Midlands Ambulance Service, it should have been 
sent to all providers; Primary Care, Mental Health, Community Provision and Social Care. 

Having  said  that,  UHNM  takes  its  share  of  responsibility  very  seriously  and  there  are  actions  that  we  have  taken 
both as an organisation and with system providers to make a difference. I have outlined below what the Trust has 
done in an attempt to reduce the number of ambulances waiting. 

1.  The placing of 111 Kiosks at both RSUH and County EDs to allow alternative pathways out of the ED, for 

patients to take. 

2.  A  Nurse  Navigator  at  the  front  door  of  ED  –  this  is  to  support  redirection  to  alternative  places  of  care  for 

ambulatory non acute patients. 

3.  The  use  of  an  innovative  IT  system  called  ‘GP  Connect’  to  allow  direct  communication  to  hospital  teams 

from primary care which will reduce the number of patients GPs need to send to ED. 

4.  We are working with our partners in the CCG and the Vocare Urgent Care Centre (UCC) to enhance Urgent 
Care  Centre  pathways;  this  is  to  reduce  the  demand  through  the  ED  by  taking  more  patients  through  the 
UCC. 

5.  UHNM  undertakes  ‘Length  of  Stay’  reviews  for  all  long  stay  patients  to  ensure  that  they  are  discharged 
home  as  soon  as  optimized,  whilst  also  recognising  that  this  requires  the  support  of  our  out  of  hospital 
providers of care as outlined above. 

6.  West Midlands Ambulance Service (WMAS) now  have access to our  Same Day Acute  Pathways and can 

use these instead of bringing patients through ED. 

7.  We have separate hot  and cold ambulance arrival areas to segregate COVID and non COVID ambulance 

arrivals which will continue over winter. 

8.  We are working closely with social care to increase  access to the domiciliary care market and placements 
for  those  patients  that  do  not  need  to  come  into  hospital.  The  NHS  has  also  given  Social  Care  over  £4 
million of funding to increase social care provision although we are yet to see the benefits of this. 

9.  As our Community Rapid Intervention Service (CRIS) is not always appropriately accessed and utilised we 
now  position  members  of  the  CRIS  team  inside  our  ED  to  turn  around  inappropriate  conveyances  and 
attendances to the ED.  

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 10.  The CRIS is working with WMAS on access to the Ambulance Service Information System so that they can 
review  the  patients  waiting  and  remove  these  directly  from  their  list,  ultimately  reducing  the  number  of 
ambulances having to attend UHNM. 

11.  Over the last few months, we have seen a significant increase in the number of patients in our hospital beds 
that  do  not  need  to  be  there.    We  are  therefore  working  hard  with  NHS  and  Social  Care  colleagues  to 
reduce  this  number  of  patients  which  will  in  turn  allow  better  flow  of  patients  out  of  ED,  reduce  ED 
congestions and thus speed up the turnaround of ambulances.  

12.  When Primary Care staffing is available we have a GP working on the ED front door to see patients who do 

not require the services of an ED.  

In  addition  to  those  points  above  and  to  ensure  a  safe  and  consistent  approach  in  managing  ambulance  arrivals 
when  there  is  a  necessity  to  hold  WMAS  crew  and  patients  on  ambulances  (due  to  capacity  issues  in  the  ED)  a 
Standard Operating Procedure (SOP) was developed in February 2021; the staff in the ED follow this process on a 
daily basis.   

This SOP includes actions such as:  

  Prioritising patients by clinical need 
  Ensuring that all patients have their observations taken  
  Review by a Clinician whilst on the ambulance and  
  The  relocation  of  space  in  the  department,  as  required,  to  allow  the  sickest  patients  to  be  taken  into  the 

appropriate area of ED.  

As  an  organisation,  we  absolutely  recognise  the  challenges  that  ‘ambulance  holds’  have  on  both  the  ambulance 
service  and  our  patients  out  in  the  community  and  we  are  committed  to  improving  the  current  performance.  
However,  we  hope  you can see from the above that  an equal number of actions are required by other health  and 
care  organisations  and  without  which,  UHNM  alone  will  not  be  able  to  make  the  difference  required  to  reduce 
ambulance delays.   

This is a national issue which as you can see, requires a system response and therefore a Regulation 28 served to 
UHNM will not be able to provide you with the assurance you require. However, I trust this response provides some 
reassurance  that  the  Staffordshire  and  Stoke-on-Trent  health  and  care  system  is  taking  action  to  minimise  such 
delays. 

I  trust  that  the  above  information  provides  you  with  some  explanation  as  to  the  national  difficulties  and  our  local 
responses to these. However, please do not hesitate to contact me should you require any further information.  

Yours sincerely 

CHIEF EXECUTIVE  

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