Stephen Wells

Karen Harrold 
Assistant Coroner 
West Sussex Coroner’s Service 
Record Office 
Orchard Street 
Chichester 
PO19 1DD 

Dear Ms Harrold 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

2 December 2022 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Stephen Wells who 
died on 04 October 2021   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  05 
September 2022 concerning the death of Mr Stephen Wells on 04 October 2021.. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Stephen’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Stephen’s 
care have been listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise to 
the family for the delay. 

Following the inquest, you raised concerns in your Report due to the lack of follow-up 
by an Oncologist after Stephen’s liver surgery on 3 August 2020, resulting in a gap of 
one year in providing Stephen with any further chemotherapy, or other treatment or 
monitoring, which would not have been curative but would have prolonged his life. To 
summarise, you queried whether additional guidance or refresher training would be 
appropriate (for GPs when raising concerns about patient hospital / tertiary treatment, 
and for hospital doctors regarding using Datix), and you raised several concerns about 
the communication between the two Trusts, particularly when there is an inter-provider 
transfer (IPT).  

NHS  England  can  advise  that  it  is  routine  practice  in  primary  care  to  have  local 
systems in place to monitor cancer cases among patients. By September 2023, every 
local risk management supplier including Datix will need to connect to the Learn from 
patient safety events (LFPSE) service. The reporter can log the incident as occurring 
elsewhere  by  completing  the  question:  “Under  which  organisation’s  care  did  the 
incident occur”. NHS England’s Regulation 28 Working Group will notify regions and 
ICB  (Integrated  Care  Board)  quality  teams  /  ICB  patient  safety  specialists  of  any 
incident of concern occurring outside of primary care, so that this can be escalated to 
the  other  organisation.  The  Royal  Surrey  County  Hospital  NHS  Foundation  Trust 
(RSFT)  have  assured  us  that  all  consultants  undertake  yearly  mandatory  training, 
which includes the use of the Datix system and the expectation for Datix reporting of 
incidents.  

Prior to the inquest, the Surrey and Sussex Healthcare NHS Trust (SASH) and RSFT 
conducted a joint review of the Service Level Agreement (SLA). The Trusts have been 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 working  to  ensure  that  the  SLA  has  been  reviewed  and  renegotiated,  and  that  the 
learning  from  this  inquest  process  and  the  concerns  raised  as  a  result  have  been 
incorporated into the new SLA.  

RSFT  have  advised  that  they  have  developed  a  proforma  letter to  use  at  the  point 
when a patient’s care is due to be transferred to another organisation. This letter is 
due to be ratified by the Oncology department and will then be used for all patients 
where care is being transferred from RSFT to  other referring hospitals. Patients will 
receive a hard copy of this letter in person at their final face to face visit, which should 
avoid any issues with the letter being lost or delayed in a postal process, and ensure 
that the patient is clear on how and who to contact should they have concerns following 
their  transfer  of  care.  The  letter  will  then  be  copied  to  the  patient’s  GP  and  to  the 
Clinical Nurse Specialist at the receiving Trust, who will be taking on the role of the 
nominated point of contact for that patient. 

RSFT and SASH have confirmed that the firewall problem between both Trusts has 
now been resolved and electronic data connections can be seen between both RSFT’s 
and SASH’s E-Tertiary system. It is hoped that the transfer and tracking of patient care 
can be monitored during December 2022. The system will go live in January 2023 for 
all hospitals referring into and receiving patients from the RSFT cancer services. Both 
Trusts have agreed to ensure that the transfer of information for all cancer patients 
should be in line with the ‘Cancer Waiting Times: Inter Provider Transfer Policy’. The 
policy has been developed by the NHS Wessex Cancer Alliance. This policy has been 
developed  over  the  time  period  including  Stephen’s  inquest,  and  the  lessons  and 
concerns identified during this inquest have been considered during the development 
of the policy. A copy of the policy is enclosed with this response for your information. 

I would also like to provide further assurances on the national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around events, such as the sad death of Stephen, are shared across the 
NHS at both a national and regional level, and helps us to pay close attention to any 
emerging trends that may require further review and action. 

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, 

National Medical Director 
NHS England

Headquarters 
East Surrey Hospital 
Canada Avenue 
Redhill 
RH1 5RH 

Egerton Road 
Guildford 
Surrey  
GU2 7XX 

1st November 2022 

Private and Confidential 

Mrs Karen Harrold 
HM Assistant Coroner for West Sussex 

Dear Mrs Harrold, 

Re: Regulation 28: Report to Prevent Future Deaths following the Inquest into the Death 
of Stephen Wells 

We are writing in response to the Report to Prevent Future Deaths which you issued to the 
Chief Executive Officers of both the Royal Surrey NHS Foundation Trust (RSFT) and Surrey 
and Sussex Healthcare NHS Trust (SASH) following the inquest touching upon the death of 
Mr Stephen Wells, which concluded on the 16th August 2022. Given that the concerns that you 
raised mainly involved the working communication and handover of care between both Trusts, 
and the  fact  that  both  Trusts  have  been  working  together  since  the  inquest  to  address  the 
concerns  identified,  we  are  submitting  a  jointly  written  and  agreed  reply  addressing  your 
concerns.  We  would  like  to  thank  you  for  investigating  this  matter  so  thoroughly  and  for 
bringing your concerns to our attention. 

The Prevention of Future Deaths report identifies five areas of concern, and we will address 
each of these areas of concern in turn below, along with details of the discussions and actions 
that we have undertaken or plan to undertake to address the issues identified. 

1.  Whether  additional  guidance  may  be  appropriate  for  GPs  to  know where  to  raise 

concerns about patient treatment in hospital or tertiary care. 

We  have  carefully  considered  this  concern  and  believe  that  this  will  be  answered  by  the 
changes  that  are  being  put  into  place  in  response  to  Concern  5,  discussed  below.  These 
changes  will  ensure  that  both  the  patient  and  the  GP  are  aware  of  the  name  and  contact 
details of the patient’s nominated point of contact at all points in the patient’s pathway. This 
point of contact will, in almost all cases, be a Clinical Nurse Specialist. Should the GP have 
concerns about the care of their patient they would be able to raise their concerns directly with 
this nominated point of contact. 

When this process is ready to go live RSFT will communicate this to all of our GP partners 
through  direct  communication,  our  regular  monthly  GP  newsletter  and  our  regular  monthly 
‘working  together’  meeting  held  between  primary  and  secondary  care  clinicians.  This  will 
ensure that all of our local GPs are aware of the new process and that should they wish to 
raise concerns about a specific patient they can do so using the contact details provided for 

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 the nominated point of contact. The GPs local to RSFT also know that they can raise concerns 
directly  through  the  ‘working  together’  meeting  or  via  email  directly  to  the  RSFT  Medical 
Director and Deputy Medical Director. Similarly at SASH, the Surrey and Sussex GP groups 
both have a regular primary care interface meeting with the Trust’s Chief Medical Officer in 
which concerns can be raised or directly via email at any time. 

2.  Whether  further  guidance  or  refresher  training  is  needed  for  hospital  doctors 

regarding the use of the relevant Datix system. 

This concern was raised following evidence heard by yourself during the inquest that the RSFT 
witness assisting the court on governance and risk issues did not know that the doctors had 
received  letters  from  Mr  Well’s  GP  raising  concerns  about  the  lack  of  ongoing  follow  up 
following his liver surgery. 

This incident occurred at SASH and so the Serious Incident Investigation was conducted by 
SASH  with  input  from  RSFT.  There  was  therefore  no  Datix  incident  raised  at  RSFT  and 
additional documentation such as these letters would have been held at SASH rather than at 
RSFT. 

At RSFT it would not be expected that consultants upload letters such as these to Datix as 
this would not be our normal process. However, it would be expected that letters such as these 
would  have  been  identified  during  a  Serious  Incident  Investigation  and  certainly  during  the 
preparation  for  inquest.  At  this  point  these  letters  would  have  been  uploaded  by  the 
governance team to the Datix system and contained within the Serious Incident and inquest 
files. This data would then be provided to, and be reviewed by, the Trust witness assisting the 
court.  

The RSFT Medical Director has asked the Deputy Medical Director and the Lead Consultant 
for  Clinical  Governance  to  conduct  a  review  into  the  RSFT  processes  for  Serious  Incident 
Review  and  preparation  for  Inquest.  This  review  will  include  ensuring  that  all  relevant 
documents, such as letters, are identified and correctly contained within Datix and the Serious 
Incident  review  documentation,  all  documentation  should then  be  reviewed  by  any  witness 
attending  an  inquest  to  assist  the  court  on  governance  and  risk  issues.  There  is  a  similar 
process at SASH. 

To provide assurance about the raising of Datix incidents when a significant problem in patient 
care  is  identified,  both  Trusts  can  confirm  that  all  consultants  undertake  yearly  mandatory 
training which includes the use of the Datix system and the expectation for Datix reporting of 
incidents. The consultants also attend departmental and divisional governance meetings at 
which  incidents  are  discussed  that  have  been  reported  using  the  Datix  system.  There  is 
therefore  a  high  level  of  knowledge  and  awareness  across  the  consultant  body  of  the 
requirement to report incidents using the Datix system and of how to do this. The consultants, 
and  all  other  staff  members,  are  also  aware  of  the  need  to  report  any  patient  identified  as 
potentially  lost  to  follow  up  immediately  and  to  complete  a  Datix  incident  report.  Incidents 
reported on Datix involving consultants, and other medical staff, are also discussed at their 
annual appraisal as a standard part of the appraisal process. 

3.  The lack of progress made in reviewing / renegotiating the SLA bearing in mind the 
difficulties in this case were drawn to the attention of the Trusts in September 2021. 

Both  Trusts  recognise  that  greater  progress  should  have  been  made  in  reviewing  and 
renegotiating the SLA prior to the Inquest, particularly given that the Trusts were aware of the 
difficulties in this case in September 2021. We would like to thank you for bringing these issues 
to our attention both before and during the inquest. Since the inquest the Trusts have been 
working to ensure that the SLA has been reviewed and renegotiated and that the learning from 

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 this inquest process and the concerns raised as a result have been incorporated into the new 
SLA. This SLA is now awaiting its final sign off by both organisations and we have enclosed a 
copy of the updated SLA with this response for your information. 

Both Trusts have been discussing more broadly the provision of Oncology services between 
RSFT and SASH and how these may be delivered in the future. We are currently discussing 
a potential move to a new model of service delivery which would remove the division in care 
between  the  two  Trusts  and  remove the  need  for  a  significant  number  of  transfers  of  care 
between the two organisations. 

RSFT are also reviewing their Cancer and Oncology SLAs with other Trusts and incorporating 
the learning from this event into those SLA renegotiations. 

4.  An  ongoing  firewall  problem  between  the  two  Trusts  as  this  places  a  current 
reliance  on  email  rather  than  automatic  electronic  systems  especially  given  the 
failure of emails in this case to secure a much-needed appointment. 

The  firewall  problem  has  been  resolved  between  the  two  Trusts  and  electronic  data 
connections can be seen between the RSFT and SASH E-Tertiary systems. This data transfer 
is  due  to  be  further  tested  by  the  IT  and  Cancer  teams  in  the  week  commencing  the  7th 
November.  The  system  will  then  be  tested  clinically  as  part  of  a  planned  move  of  Upper 
Gastrointestinal Oncology patients currently managed by SASH to the care of RSFT later in 
November when each patient will require a transfer of information. 

Assuming that the testing scheduled for November is successful all RSFT cancer staff will be 
trained  on  the  correct  use of the  E-Tertiary  system  and  the transfer  and tracking  of patient 
care during December. The system will then go live for all hospitals referring into, and receiving 
patients from, the RSFT cancer services in January 2023.  

Both Trusts have agreed to ensure that the transfer of information for all cancer patients should 
be  in  line  with  the  ‘Cancer  Waiting  Times:  Inter  Provider  Transfer  Policy’  which  has  been 
developed by the Surrey and Sussex Cancer Alliance. This policy has been developed over 
the  time  period  including  this  inquest  and  the  lessons  and  concerns  identified  during  this 
inquest have been considered during the development of the policy. A copy of the policy is 
enclosed with this response for your information. 

RSFT  is  also  working  with  all  of  the  hospitals  who  refer  patients  into  the  Trust  for  cancer 
services to ensure that they also follow the practice laid out in the Surrey and Sussex Cancer 
Alliance policy. 

5.  Concerns that that there is insufficient clarity for both patients and staff as to the 
identity of the key contact for the patients care when there is an IPT from SASH to 
RSFT and vice versa. 

Following  the  concerns  identified  during  the  inquest  the  Trusts  have  been  working  on  an 
agreed pathway that will ensure that patients themselves receive a letter at the point when 
their  care  is  due  to  be  transferred  to  another  organisation.  This  letter  will  contain  the  key 
contact details including a telephone number for the nominated point of contact at the receiving 
organisation. The patient will therefore always have the key contact details available to them. 
The letter will also be copied to the patients GP and to the receiving clinical nurse specialist 
at the receiving hospital. This ensures that the GP has access to the contact details of the 
nominated point of contact should they need to raise any concerns or otherwise make contact 
with  the  treating  clinical  team.  The  Inter  Provider  Transfer  process  will  continue  to  be 
conducted  in  accordance  with  the  Surrey  and  Sussex  Cancer  Alliance  policy  described  in 
Concern 4. 

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 RSFT have developed a proforma letter to use at the point when a patient’s care is due to be 
transferred  to  another  organisation.  This  letter  is  due  to  be  ratified  by  the  RSFT  Oncology 
department  on  the  4th  November  and  will  then be  used for  all  patients  where care  is  being 
transferred from RSFT to our referring hospitals. Patients will receive this letter in person at 
their final face to face visit, this will avoid any issues with the letter being lost or delayed in a 
postal process and ensure that the patient is clear on how and who to contact should they 
have concerns following their transfer of care. The letter will then be copied to the patient’s 
GP and to the Clinical Nurse Specialist at the receiving Trust who will taking on the role of the 
nominated point of contact for that patient. 

On behalf of both Trusts we would like to take this opportunity to offer our sincere condolences 
to Mr Wells’ family for their loss. We hope that the actions outlined above assure you that we 
are committed to identifying learning and improving the quality of care for our patients. 

Yours Sincerely 

Chief Executive Officer  
Royal Surrey NHS Foundation Trust  

Chief Executive Officer  
Surrey and Sussex Healthcare NHS Trust 

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