John Heffron

Chief Medical Officer and 
Deputy Chief Executive 
Trust Headquarters 
St James’s University Hospital 
Beckett Street 
Leeds 
LS9 7TF 

Date: 4th November 2022 

Mr Kevin McLoughlin 
Senior Coroner 
West Yorkshire (Eastern) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Mr McLoughlin 

INQUEST TOUCHING THE DEATH OF JOHN FRANCIS HEFFRON (deceased) 

I  write  in  response  to  the  Report  to  Prevent  Future  Deaths  dated  18th  August  2022  sent  to  Leeds  Teaching 
Hospitals  NHS  Trust  following  your  investigation  into  the  death  of  Mr  John  Francis  Heffron  and  the  inquest 
concluded on 17th August 2022. 

The Regulation 28 Report has been shared with relevant staff in the Trust and this response provides details 
of action taken by the organisation in response to the concerns set out in it.  

In your report the matters of concern are set out as follows: 

(1) There  was  a  delay  between  the  patient  being  found  in  an  unresponsive  condition  and  CPR  being
initiated.    Although  the  evidence  as  to  the  material  times  was  not  entirely  reliable  the  Trust’s
investigation  indicated  that  the  patient  had  been  found  unresponsive  around  1.15am,  yet  the
statement of the registrar on duty stated she was called at 1.30am.  There was then an interval of time
whilst the patient’s DNAR status was ascertained from the computerised medical records.

(2) The  lady  working  as  a  bank  nurse  in  the  ED  who  found  the  patient  unresponsive  admitted  to  the
Trust’s investigator, she was not familiar with the crash call system.  She did not press the buzzer to
initiate  a  crash  call.    The  extent  of  her  training  in  CPR  was  unclear.    It  is  understood  she  normally
worked on a part-time basis in an outpatient unit.

(3) The experienced nurse alerted to the situation also did not press the crash call  buzzer.  She appears
not to have examined the patient, but instead telephoned the sister in charge of the ED to report the
patient had died.  She admitted to the Trust’s investigator that she was overwhelmed.

(4) When CPR was commenced, a return of spontaneous circulation was achieved at 1.50am.  A CT scan

at approximately 4.30am indicated a hypoxic brain injury had been sustained.

The Leeds Teaching Hospitals incorporating: 
Chapel Allerton Hospital    Leeds Dental Institute    Seacroft Hospital    Leeds Children’s Hospital 
St James’s University Hospital    Leeds General Infirmary    Wharfedale Hospital    Leeds Cancer Centre 

 
 
 
 
 
 
 (5)  Evidence taken at the inquest indicated the collapse and/or death of a patient in the ED is known to 
occur sometimes.  It  is a foreseeable risk.  Hence there is a need  for the nursing staff to be  trained 
and familiar with the emergency systems in place, in order to be able to respond appropriately. 

(6)  It was unclear what steps had been taken by the Trust prior to 12th December 2021 to establish: 

i. 
ii. 

iii. 

the nursing qualifications of bank and/or agency staff permitted to work in the ED. 
whether  bank  and/or  agency  staff  hold  appropriate  and  current  training  in  resuscitation 
procedures. 
whether  a  suitable  induction  system  was  in  place  to  ensure  bank  and/or  agency  staff  were 
familiar with the crash call system. 

(7)  The  Trust  saw  the  need  to  initiate  a  “Serious  Incident  Investigation”  but  allocated  this  work  to  a 

person: 
i. 

present  in  the  ED  at  the  time  of  the  incident  and  thus  not  independent  of  the  events  being 
examined. 
who  had not  been  trained  in such  investigations save for  a  one-day course some five years 
previously and had never undertaken one of this nature before. 
who  spoke  to  the  staff  involved  during  the  shift  on  the  night  of  the  incident,  only  when  time 
permitted, alongside their other work.  No written statements were obtained.  In consequence, 
the precise chronology of events is unclear. 
no context was provided which may have enabled an assessment of the workload or staffing 
levels in the ED at the material time. 

ii. 

iii. 

iv. 

For  these  reasons  the  inquest  felt  unable  to  rely  upon  the  conclusions  reached  in  the  Serious  Incident 
Investigation Report 

(8)  It  is  acknowledged  that  some  additional  refresher  training  has  been  carried  out  since  this  incident.  
There  is,  however,  no  system  of  audit,  spot  checks  or  dip  testing  to  verify  that  bank  and/or  agency 
nurses are actually familiar with the essential procedures relating to crash calls. 

(9)  It  was  unclear  whether  the  Trust’s  contractual  arrangements  with  nursing  agencies  stipulate  the 

requirements for those supplied to: 

i. 
ii. 
iii. 

be professionally qualified. 
have current training to specified standards. 
have undergone appropriate induction to the ED. 

We have considered these carefully and our response is set out below. 

(1)  The  Trust  acknowledges  that  there  was  a  delay  in  CPR  being  commenced  after  the  patient  had  been 
found  in  an  unresponsive  condition  and  there  were  discrepancies  in  the  evidence  for  the  inquest  about 
timings. However, the senior sister stands  by the account that she gave  in court  i.e.,  that she had  been 
contacted at 01.15am, after the doctor had been approached, and that she attended immediately after the 
call to her, by which time CPR was being undertaken.  In her statement for the inquest, she explained that 
her discussions with the relevant team members afterwards indicated that CPR had been started within 30 
to 60 seconds of the patient being found.  The Trust understands that it was Dr Binbay’s recollection that 
she  had  been  contacted  at  01.30am  however  this  was  not  supported  by  other  staff  members.  
Unfortunately, the doctor was not called to give evidence at the inquest and therefore this issue could not 
be explored any further.  Whilst respecting your findings at the inquest, the Trust does not accept that the 
period of delay in commencing treatment for the cardiac arrest with CPR was as long as 15 minutes.  It is 
accepted  however  that  obtaining  statements  from  staff  during  the  incident  investigation  would  have 
provided more robust first hand evidence.  

(2)  The bank nurse on duty in the ED on 12th December 2021 was up to date with the Trust’s mandatory and 
priority training for all nurses.  She had completed the Trust’s level 1 Resuscitation training course.  This 
meets the statutory and mandatory training requirements and learning outcomes for Resuscitation level 1 
in the UK Core Skills Training Framework (UK CSTF). The course objectives are as follows: 

•  To recognise when someone’s heart has stopped (cardiac arrest). 
•  The best way of getting immediate help. 
•  How to carry out chest compressions. 
•  What to do if an adult is choking. 

(3)  The Covid 19 pandemic and its legacy have had a profound effect on the work of the Trust and both of its 
Emergency Departments.  It has impacted on the numbers of patients attending; the way in which they are 

 
 
 
 
 
 
 
 
 
 
   
 managed in the departments, (and elsewhere in our hospitals), and the workforce required to assess and 
treat them.  In response to this we have had to expand the size of our Emergency Department footprint; 
increase  the  senior  leadership  presence  in  the  department,  with  band  7  nursing  cover  24  hours  a  day 
alongside  new  Matron  leadership  and  allocate  significant  investment  into  the  nursing  workforce  to  help 
with  the  care  and  treatment  of  our  patients.    There  is  a  robust  Bronze  Command  structure  to  facilitate 
efficient  escalation  of  concerns  about  resourcing  in  and  out  of  hours  and  there  is  an  internal  reporting 
system  known  as  SafeCare  that  enables  staff  to  flag  workforce  issues  as  they  arise.    This  increased 
resource has improved the support the Trust provides to staff working on the frontline and is intended to 
minimise instances of individual members of staff feeling overwhelmed by their workload.  

It is accepted that in this case there were deficiencies in the response of the experienced nurse on duty to an 
emergency  when  she  failed  to  press  the  crash  buzzer  or  examine  the  patient  after  finding  him  in  a  state  of 
cardiac  arrest.   However, the same nurse did seek medical  advice immediately from a doctor,  in addition to 
telephoning  the  sister  in  charge.    The  recollection  of  the  staff  member  involved  at  the  time  is  that  both 
responded  to  her  requests  for  assistance  very  promptly.    Additional  support  and  refresher  training  was 
provided to the nurse following the incident.  It is envisaged that with the changes that have been made which 
are referenced above and below, the likelihood of a recurrence of such an incident are very low.  

(4)  Your summary of the resuscitation and investigations conducted after it is noted. 

(5)  All nursing staff employed by the Trust as substantive members of staff attend corporate induction training 
on their first day of employment.  Within 28 days of starting work they must also complete local induction 
within  their  specific  department  or  area  of  work.    To  evidence  local  induction  there  is  a  standardised 
template that must be completed which details the procedures that must be covered with the new starters; 
this includes action to take in an emergency, and local procedures for resuscitation.  

In the Urgent Care Clinical Service Unit new members of staff receive a new starter booklet which explains the 
mandatory and priority training they must undertake, with emphasis on its importance to the work they will be 
doing.  All new nurses in the ED work in a supernumerary capacity for 6 weeks while they complete their basic 
training and familiarise themselves with the department and the processes in place within it.  This system was 
in place at the time of Mr Heffron’s death.   

The training and qualifications required for agency and bank nurses working in the ED are set out below. 

(6)  In  December  2021  the  Trust  followed  a  framework  employment  checklist  for  temporary  workers  on 
temporary assignments, to establish their qualifications and training prior to them  starting work in the ED.  
This  still  remains  the  case.    Staff  allocated  by  the  preferred  provider  to  work  in  the  EDs  should  only  be 
staff with prior  ED experience.  Checks made cover  the  individual’s qualifications, skills  and  experience, 
their DBS status and completion of the Trust’s mandatory and priority training (including refresher training 
and  updating);  resuscitation  training  forms  part  of  this.    A  CV  is  received  for  each  candidate  in  order  to 
verify skills and experience based on previous employment history.  Once an agency worker is accepted 
by  the  Trust  they  receive  training  in  our  clinical  systems,  including  the  electronic  health  record  system 
(PPM+); Symphony (the ED health record system); e-Obs (electronic observations) and Emeds (electronic 
prescribing/medicines  management  system).    All  agency  nurses  complete  a  supernumerary  shift  where 
they are buddied with a Trust member of staff and local induction is completed. 

In  this  case  the  nurse  involved  in  caring  for  the  patient  on  12th  December  2021  was  a  substantive  Trust 
employee.  For these staff their substantive skill set holds true, as does their mandatory and priority training 
requirements.    Currently  there  are  no  additional  checks  on  completion  of  mandatory  and  priority  training  or 
DBS  when  substantive  staff  apply  for  the  staff  bank.    This  is  because  compliance  with  all  mandatory  and 
priority training elements is a requirement of their substantive position and is subject to regular reporting and 
review. As highlighted in response (2) above, the bank nurse in question was up to date with all her training 
requirements including resuscitation training. 

Following the patient’s death, and during the investigation into the care provided before it, the Trust identified 
deficiencies  in  the  training  provided  for  bank  and  agency  staff  about  the  crash  call  process  used  by  the  ED 
teams and action has been taken to address these.  

Checks  are  now  undertaken  by  the  nurse  in  charge  at  the  start  of  every  shift  to  identify  new  starters.    In 
addition,  a  local  induction  checklist  is  completed  during  the  individual’s  first  shift  in  the  department.    This 
completed  checklist  is  signed  by  both  the  member  of  staff  and  the  nurse  in  charge  to  provide  documentary 
evidence that the process has been completed.  This provides assurance that all temporary staff have been 
orientated  to  the  department,  have  received  explanations  in  regard  to  resuscitation  procedures  and  the 
location of essential items of equipment including call bells, crash trollies, fire exits.  It also confirms they have 

 
 
 
 
 
 
 
 
 
 
 an  understanding  of  the  procedures  for  reporting  incidents  and  evacuating  the  department.    During  Matron 
assurance  walk  rounds,  the  nurse  in  charge  undertakes  spot  checks  to  ensure  that  temporary  staff  meet 
departmental requirements and to identify any gaps in their knowledge that may need addressing.  

(7)  The  investigation  into  the  care  provided  to  this  patient  was  not  a  Serious  Incident  Investigation  (level  3) 
within  the  terms  of  NHSE’s  Serious  Incident  Framework.    Within  the  Trust  there  is  a  grading  process  to 
decide  which  incidents  will  be  fully  investigated.  There  are  three  main  considerations  when  making  this 
decision: 

•  The level of severity of harm to the patient/carer/relative or staff member. 
•  The likelihood of the event recurring. 
•  The potential for learning 

To  help  staff  determine  the  level  of  investigation  to  be  conducted  a  risk  matrix  is  used.    This  provides  a 
grading based on the consequence and likelihood of recurrence.  Incidents are initially reviewed locally (within 
the Clinical Service Unit - CSU).  If an incident is believed to fall within the definition of a Serious Incident, it is 
escalated to the corporate Risk Management team in accordance with the Trust’s Procedure for the Reporting 
and Management of Serious Incidents (SIs).  The incident is then considered by the Chief Medical Officer and 
Chief  Nurse  to  determine  whether  it  should  be  declared  as  a  Serious  Incident;  if  it  is,  an  investigator 
independent of the CSU is appointed to lead the investigation.  

In  accordance  with  the  Trust’s  Investigation  Procedure,  the  incident  report  relating  to  Mr  Heffron  was 
discussed  with  the  senior  nursing  team  in  the  CSU  and  one  of  the  ED  Consultants  who  is  the  lead  for  risk 
related  matters  in  the  department.    At  this  time  the  incident  was  scored  at  5  (likelihood  of  occurrence  rare; 
consequence  catastrophic).    During  the  discussions  it  was  clear  that  at  that  stage  the  length  of  the  delay 
between Mr Heffron being found in cardiac arrest and resuscitation starting was uncertain.  It was agreed that 
if  the  delay  was  found  to  be  significant  then  the  incident  would  need  to  be  escalated  as  a  potential  serious 
incident.  If the delay was found to be of short duration, then the incident could be investigated locally.  From 
initial discussions with staff involved a senior member of the nursing team was able to establish that there had 
been no meaningful delay and that the incident would be investigated locally.  

For  incidents  with  a  risk  score  of  1-6  there  is  no  requirement  for  staff  to  complete  a  formal  investigation 
template.  The Trust’s Investigations Procedure explains that reviews may involve the multi-disciplinary team 
exploring ways to minimise a recurrence, or a review of the care plan.  The procedure includes a contributory 
factors checklist and advises staff that this may provide a useful prompt for the review.  Staff are required to 
document the outcome of the review on the investigation tab of the Datix incident form, along with details of 
any further action planned.  The department/service should take the responsibility to identify learning points or 
safety improvement measures which are within the department’s control and the line manager should ensure 
that  any  issues  which  are  out  of  their  control  are  communicated  to  the  General  Manager  (or  equivalent)  for 
consideration/action. Lessons learned must be clearly documented.  

Although the incident  relating to Mr Heffron  had  been risk scored at 5, the team decided that a more formal 
investigation  would  be  appropriate  and  agreed  that  a  level  1  investigation  would  be  undertaken,  (usually 
undertaken for incidents scoring between 8-12), and this would be led by the nursing sister on duty at the time. 
The  Trust’s  Investigations  Procedure  states  that  level  1  investigations  should  usually  be  carried  out  by  the 
ward/departmental manager or clinical lead.  It further explains that the investigation and analysis should  be 
carried  out  by  a  suitably  trained  person  (i.e.  staff  who  have  completed  root  cause  analysis  training)  and  an 
attempt should be made to establish a root cause.  

At  the  inquest  the  senior  sister  confirmed  she  had  completed  lead  investigator  training,  albeit  several  years 
prior to undertaking the investigation into the incident relating to Mr Heffron.  Historically, investigation training 
has  been  provided  as  a  one-off  course  as  in  the  normal  course  of  events  staff  start  to  utilise  the  skills  they 
have acquired quite quickly after attending their training.  

A review of the Trust’s incident reporting system shows that the senior sister had reviewed 1060 incidents in 
her role in ED and as senior sister on one of the Acute Medicine wards.  From these incidents she had led on 
16 investigations.  It is true to say that with the exception of one incident, all of these were related to in-patient 
falls; healthcare associated infections and hospital acquired pressure ulcers.  These incident types have their 
own  root  cause  analysis  templates  which  look  very  different  to  the  level  1  investigation  report.    The  senior 
sister had completed one level 1 report previously.  The investigation she undertook into the incident relating 
to Mr Heffron was overseen by one of the ED Matrons and therefore this was not conducted in isolation.  It is 
accepted that ideally the investigation should have been undertaken by a member of staff who had not been 
on shift when the incident occurred, but the Trust’s Investigations Procedure does not specifically require this 
as  investigations  are  not  undertaken  in  isolation  of  other  members  of  the  team.    Only  serious  incidents  are 
investigated by someone completely independent of the CSU.   

 
 
 
 
 
 
 
 
 
 In relation to your observations regarding the chronology of events it is noted that the incident summary in the 
investigation report does contain an outline chronology of events.  It is acknowledged that it would have been 
helpful if this had contained more detail  in regard to the time of the doctor’s attendance and if the report had 
been  supported  by  notes  of  discussions  with  relevant  staff.    The  Trust’s  Investigation  Procedure  includes  a 
range of tools and templates to assist staff when conducting investigations and whilst use of these is actively 
encouraged,  it  is  not  mandated.    In  response  to  the  specific  concerns  raised  about  the  investigation  of  this 
incident,  the  Trust  has  provided  the  ED  senior  nursing  team  with  a  memory  capture  tool  to  promote  prompt 
and consistent recording of staff involvement in incidents and to formalise the evidence gathering stage of the 
investigation. 

You  will  be  aware  from  previous  discussions  that  the  Trust  has  been  a  pilot  site  for  the  new  Patient  Safety 
Incident  Response  Framework  (PSIRF)  which  will  replace  the  current  Serious  Incident  Framework.    It 
represents a significant shift in the way the NHS responds to patient safety incidents.  The PSIRF promotes a 
range  of  system-based  approaches  for  learning  from  patient  safety  incidents  and  national  tools  and  guides 
have been produced to support this.   

As a pilot site the Trust has had the opportunity to trial the new approaches and better understand the training 
requirements that  will need to be delivered.   All Trust staff charged with undertaking reviews  under the  new 
framework will receive training in how to conduct and record them.  Support and advice, and regular updating 
sessions, will also be provided.  The Urgent Care CSU has planned some bespoke sessions for their senior 
staff  with  the  Trust’s  Risk  Management  team  to  complete  training  in  relation  to  the  new  investigation 
documentation.  This  will  help  ensure  that  learning  from  incidents  is  maximised  and  documentation  is 
completed to a high standard.  

Your  comments  about  the  absence  of  any  context  regarding  workload  and  staffing  levels  on  the  day  of  the 
incident are noted.  The purpose of the investigation was specifically in relation to establishing whether there 
was a significant delay in commencement of CPR after the patient was found unresponsive; whether he had 
been  receiving  an  appropriate  level  of  monitoring  at  the  time  he  was  found  unresponsive  and  whether  any 
additional cardiac monitoring should have been in place prior to the patient’s arrest.  The timeline of events in 
the  investigation  report  showed  that  the  patient  was  reviewed  at  regular  intervals,  albeit  that  some  of  the 
intervals  were  longer  than  the  agreed  target  times,  and  that  he  had  the  appropriate  investigations.    As 
highlighted in point 3 above, over the last two years the EDs have experienced an unprecedented demand in 
terms  of  attendances;  patients  requiring  admission  and  an  increase  in  the  acuity  of  patients  requiring 
treatment.  The actions detailed are designed to help address these issues. 

(8)  From  the  response  provided  in  point  6  above,  I  hope  that  you  will  be  reassured  that  appropriate  audit 
arrangements  are  now  in  place  in  the  Trust  to  check  bank  and  agency  staff’s  familiarity  with  essential 
procedures in the ED, and to ensure that they have the knowledge base and confidence to follow them as 
required.  

(9)  As  detailed  in  our  response  to  point  6  above,  the  Trust’s  contractual  arrangements  with  agencies 
supplying nursing staff requires that the staff supplied have full and current nursing qualifications, together 
with up-to-date training to specified standards in areas relevant to the work they will be undertaking.  Bank 
staff  supplied  to  the  ED  by  the  Trust’s  internal  deployment  team  must  meet  the  same  standards.    All 
nurses  working  in  the  ED  are  required  to  undergo  departmental  induction,  whether  they  are  substantive 
members of staff, agency, or bank nurses.  

Thank  you  for  bringing  these  issues  to  my  attention.  I  hope  that  this  response  provides  confidence  that  the 
Trust has considered and addressed them appropriately. 

If I can be of any further assistance, please do not hesitate to contact me. 

Yours sincerely 

Chief Medical Officer and Deputy Chief Executive 
Leeds Teaching Hospitals NHS Trust