Nicholas Pennicott

Ms Penelope Schofield 
Coroner’s Court 
Woodvale 
Lewes Road 
Brighton  
BN2 3QB 

Dear Ms Schofield, 

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

26 July 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Mr Nicholas John Pennicott 
who died on 19 August 2021. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 May 
concerning the death of Nicholas John Pennicott on 19 August 2021. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Nicholas’  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the coroner that the concerns raised about Nicholas’ care have 
been listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Nicholas’ family or friends. I realise that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

In  your  Report,  you  raise  a  concern  regarding  the  hospital  waiting  times  for  a 
Neurology outpatient appointment at the University Hospitals Sussex NHS Foundation 
Trust (UHSUSSEX) due to capacity issues. I have been sighted on their response to 
your  Report and  note that  since  July  2022,  they  are operating under  a  new  clinical 
operating model which has improved neurology capacity at UHSUSSEX.   

This  includes  consultant-led  triaging  of  referred  patients,  providing  advice  and 
guidance to GPs and other hospital consultants, and reduction in administrative time 
taken to register referrals. I note that the Trust aims to see urgent referrals within 4 
weeks  and  has  committed  to  making  further  improvements  across  its  neurology 
service.  

Regarding staffing challenges within the neurology workforce at UHSUSSEX, I note 
from  their  response  to  you  that  they  are  in  the  process  of  recruiting  to  additional 
consultant posts. I am advised that there are currently two consultant vacancies, but 
that one locum is in place and that UHSUSSEX has also engaged Elective Services 
to  provide  additional  outpatient  capacity  in  the  interim  period  while  recruitment  is 
ongoing.  

                                                                                                                       
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
   
 Your Report also raises a concern that there is a shortage of neurologists at a national 
level. This is a well-recognised issue within the NHS and there is currently significant 
variation  in  neurologist  numbers  across  England.  The  Getting  It  Right  First  Time 
(GIRFT)  programme  for  neurology  (GIRFT  is  national  NHS  England  programme 
designed to improve the treatment and care of patients through clinically led reviews) 
recommends that all acute hospitals have acute neurology liaison services in place, 
and,  ideally,  acute  neurology  outpatient  clinics  to  urgently  see  rapidly  deteriorating 
patients. However, this is dependent on workforce constraints.  

Last month, NHS England published the NHS Long Term Workforce Plan, setting out 
our plans to grow, retain and reform our workforce across the next fifteen years. This 
plan looks to reduce the national shortages we see across the NHS, helping to provide 
safe and timely access to urgent care that will reduce the delays currently being faced 
by patients such as Nicholas.  

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national 
and regional level and helps us 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

26 July 2023 

Ms Penelope Schofield 
Senior Coroner for West Sussex, Brighton and Hove 
County Records Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

Worthing Hospital 
Trust HQ 
Lyndhurst Road 
Worthing 
West Sussex 
BN11 2DH 
Tel: 01903 205111 
www.uhsussex.nhs.uk 

Dear Ms Schofield 

RE: Inquest touching upon the death of Mr Nicolas Pennicott 

In April 2023, the Trust provided information to the Coroner about developments in neurology services 
since Mr Pennicott’s death (letter dated 12 April 2023). At the end of the inquest, you asked for an 
update at the end of July 2023 on measures the Trust intended to introduce but were not in place or 
fully in place in April 2023. I am writing to provide you with that update on the development of 
neurology services at Worthing and St Richards Hospitals.  

The service introduced the new e-RS system for managing referrals on 2nd May 2023. 

Advice and Guidance service for GPs  

•  The Trust now has 3 consultant sessions per week for neurology consultants to provide advice 

and guidance for GPs. This is a new facility which was introduced in May 2023, for GPs to access 
advice prior to or instead of referring for an outpatient clinic  

•  GPs can select the advice and guidance dropdown option when they are using ERS to refer 

• 

patients. We are now receiving up to 10 requests per week so are confident that GPs are aware of 
this service and able to access it 
 A wider communication with primary care updating on developments has been written to increase 
awareness amongst GPs of this facility and we expect this to be shared in the primary care 
newsletter published by the ICB in August 

•  This will include an update to the Directory of Services for neurology clearly identifying the advice 

and guidance facility along with other specialist clinics provided 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Triage for outpatient clinic referrals 

•  Patients referred for outpatient clinic are triaged by a consultant neurologist and categorised by 

clinical urgency based on the information provided by the GP 

•  The triage criteria were updated as planned in May 2023. We have introduced a pre-screen to 

assist the consultant triaging and ensure any patient already known to the service is made known. 
The consultant is triaging by urgent, 2 week wait cancer, first seizure or routine.        For urgent 
referrals, the consultant is indicating the maximum number of weeks they would expect the patient 
to be seen within 

•  We have introduced regular monitoring of the waiting list, with reviews of urgent patients waiting to 

• 

be seen to allow appropriate prioritisation within available clinic capacity 
Implementation of the e-RS system has reduced the previous delay to uploading referrals for 
consultant triage 

Waiting times for patients referred to outpatient clinics 

•  We have now employed a locum consultant neurologist to support the service and provide 

additional outpatient clinics and consultant triage. This arrangement is ongoing  

•  We have engaged Elective Services to provide additional outpatient capacity to address waiting 

times for new patients and anticipate that these measures will reduce waiting times for all patients. 
Elective Services are providing in excess of 600 outpatient appointments over a 12-week period 
•  We have advertised for substantive consultant neurologists. The advert closes on 26th July and 

we look forward to shortlisting any applicants 

•  We are implementing changes to manage the demand for new outpatient appointments across 
the 3 sites within the Trust to reduce the maximum waiting time for patients across Sussex., 
offering patients appointments at alternative sites to reduce waiting time 

Neurology workforce review 

•  There remain significant pressures on the neurology medical workforce with national and local 

consultant shortages 

•  We continue to develop our model of advanced clinical practice in neurology with a team of 

clinical nurse specialists working in general neurology as well as in specialist areas, including 
headache, epilepsy and Parkinson’s disease. We have developed a proposal to increase the 
capacity of the services that ACPs are providing and expect to deliver this in the second half of 
this financial year 

Advice and guidance for hospital consultants 

•  A Standard Operating Plan (SOP) is in place for the Emergency Department / Emergency Floor 
consultants to access advice from a consultant neurologist on weekdays. At weekends, advice 
can be sought from the on-call neurology teams at Southampton General Hospital or Royal 
Sussex County Hospital 

 
 
 
 
 
 
 
 
 
 
 •  The department uses an electronic referral form that initiates a review by a consultant neurologist. 
During the week, this should be provided on a same day basis.  If there are staffing constraints on 
a specific site then cross site solutions such as telephone advice are available. There is a 
consultant neurologist on call daily across the Trust. There is a regular ward review service for 
patients on the wards at St Richards Hospital and Worthing Hospital, by a consultant neurologists 

Yours sincerely 

Chief Executive