Maureen Harrop

Alison Mutch 
HM Senior Coroner 
Coroner’s Court  
1 Mount Tabor Street  
Stockport  
SK1 3AG 

Dear Ms Mutch, 

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

18 January 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Maureen Harrop who died 
on 21 January 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  14 
September  2022  concerning  the  death  of  Maureen  Harrop  on  21  January  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Maureen’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Maureen’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  regarding  Maureen’s 
prolonged stay in the Emergency Department at the Hospital because of lack of bed 
capacity,  as  well  as    the  delayed  surgery  (exceeding  the  36  hour  timeframe 
recommended by NICE guidance) due to a lack of theatre capacity, and the significant 
impact this prolonged wait will have had on Maureen’s overall physiological reserves. 

NHS  England  has  engaged  with  the  Tameside  and  Glossop  Integrated  Care  NHS 
Foundation  Trust  (ICFT)  in  order  to  respond  to  this  Report,  and  appreciates  their 
helpful input.  

The Trust recognises that hip fractures are very common, especially in older people 
where fractures can have a significant impact upon their overall health and lives. At 
ICFT, it is recognised that there have been significant challenges throughout the hip 
fracture  pathway.  The  Trust’s  response  to  the  Covid  pandemic  and  prolonged 
increased activity impacted on the service’s ability to treat and manage patients within 
the appropriate processes and timeframes.  

At the time of Maureen’s admission to Tameside General Hospital, the Trust, like other 
Trusts nationwide, was experiencing sustained and significant operational pressures 
within  the  Emergency  Department  (ED)  and  wider  hospital,  and  was  responding  to 
continuous Covid challenges and pressures. The Trust had separate areas for Covid 
positive  and  non-Covid  patients,  as  set  out  in  NHS  England  national  planning 
guidance,  which  contributed  to  delays  in  Maureen  being  triaged  and  subsequently 
transferred to an appropriate bed. The Trust has now been able to reinstate previous 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 care pathways due to a decline in the national incidence of Covid positive cases. This 
means that the bed base of trauma and orthopaedics has been increased to near pre-
pandemic levels.  

The  Surgical  and  Medical  Division  have  worked  closely  together  to  design  and 
implement an enhanced bed allocation process. The process supports those patients 
with hip fractures from the moment that the patient has had their fracture confirmed in 
the  ED,  through  to  admission  to  a  trauma  and  orthopaedics  bed.  The  pathway 
redesign has included both in and out of hours actions required by the clinical teams, 
with support from the Trust’s patient flow team. Each Trust bed meeting, which occurs 
five times per day, highlights any patient within the ED who will require a Trauma and 
Orthopaedic bed due to a hip fracture.  

In response to your second concern, the Trust recognises that best practice and NICE 
guidance  states  that  patients  that  have  sustained  a hip  fracture  should  have  timely 
surgery to repair the injury within 36 hours of admission, where the patient is clinically 
stable to undergo surgery - Overview | Hip fracture: management | Guidance | NICE. 
To  manage  these  patients  within  the  appropriate  timeframe  alongside  competing 
priorities within the trauma and elective services, the Division of Surgery, Women’s 
and Children’s services (SWC) have reviewed and strengthened their processes.  

The trauma and orthopaedic department run a daily trauma meeting, where all patients 
with hip fractures who are awaiting surgery are identified. Individual plans of care and 
management are agreed clinically with the on-call orthopaedic consultant and trauma 
coordination team. An overview of these patients is also provided to the surgical bed 
meeting each morning, including the status of each patient and the current wait time 
for surgery.  

For those patients who can proceed to surgery, this will be scheduled to take place 
within the 36 hour timeframe to support compliance with NICE guidance. If this is not 
possible due to a theatre not being available, an urgent review of the entire trauma 
and  elective  lists  that  day  will  be  undertaken.  A  clinical  and  operational  discussion 
determines how the patient can be accommodated, and a plan is then devised. The 
detailed plan is then enacted with the approval of the Divisional Management Team 
(DMT) and the patient is scheduled into theatre. 

For those patients who are deemed  unfit for surgery, the trauma coordination team 
supports  the  orthopaedic  and  anaesthetic  clinicians  to  determine  the  appropriate 
clinical plan. This plan is discussed at the daily trauma planning meeting. For patients 
who  may  require  diagnostic  tests  as  part  of  their  pre-operative  optimisations,  daily 
tracking of these is also included within the daily planning meeting.  

Where the Trust is not able to meet the 36 hour timeframe for surgery for a patient 
with a hip fracture, a clinical incident report is submitted. Following the incident, a root 
cause analysis (RCA) is completed by the trauma coordinators to identify the reasons 
for  the  delay  and  opportunities  for  learning.  The  RCA  investigations  are  reviewed 
weekly  in  the  “Neck  Of  Femur  (NOF)  Review  Meeting”  for  comment,  action  and 
approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron 
for Trauma and Orthopaedics and the Directorate Manager. Compliance is monitored 
through regular internal returns. 

 
 
 
 
 
 
 The Trust also submits data to the National Hip Fracture Database, which specifically 
looks  at  care  for  patients  over  the  age  of  60,  who  undergo  surgery  following  a  hip 
fracture. This includes data to improve care through quality improvement, in line with 
NICE  guidelines  and  the  National  Falls  and  Fragility  Fracture  Audit  Programme 
(FFFAP). Data is submitted by the trauma coordinators daily.  

In  addition  to  this,  the  Trust  has  implemented  a  Divisional fractured  neck  of  femur 
improvement  programme,  which  is  reported  and  monitored  daily  via  the  Divisional 
senior leadership team. Oversight of Divisional compliance with this pathway is also 
monitored  via  the  Service  Quality  and  Governance  Group,  which  is  chaired  by  the 
Executive Director of Nursing and Integrated Governance. 

I would also like to provide further assurances on the national NHSE work taking place 
around  the  Reports  to  Prevent  Future  Deaths  generally.  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 
Maureen, 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