Hilary Thomas

15 August 2023 

For the attention of Louise Hunt 
Senior Coroner for Birmingham and Solihull 
Birmingham Coroner’s Court 
50 Newton Street 
Birmingham 

Dear Mrs Hunt 

Inquest touching the death of Hilary Thomas 

Response to Regulation 28 Report to prevent future deaths 

I write in response to the Regulation 28 Report made by you following the Inquest touching 
the death of Mrs Thomas which concluded on 26 June 2023 

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered 
the concerns raised within your report to prevent future deaths relating to three matters of 
concern: 

Department of Health and Social care 

1.  Witnesses explained at the inquest that the volume of patients attending hospital is at 
a level the like of which has never been seen and current resources are unable to 
deal with that volume. This had a direct impact on Mrs Thomas's death as the doctor 
treating her was unable to review her blood tests results until the evening handover, 
6 and a half hours after the results were available by which time Mrs Thomas had left 
the department. 

University Hospitals Birmingham NHS Foundation Trust 

2.   Mrs Thomas re-attended hospital with severe pain, was over age 70 and an 
unscheduled return within 72 hours. The Doctor should have considered and 
followed national guidance from the Royal College of Emergency medicine published 
in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been 
reviewed by a consultant. Mrs Thomas was not escalated for consultant review. 
There was no evidence at the inquest that this guidance has been adopted by the 
Trust nor that staff are aware of it and have been trained on it. 

3.  The doctor treating Mrs Thomas on her second attendance decided to wait for blood 
test result before ordering a CT scan under the misunderstanding that these were 
required to assess the possibility of renal toxicity from dye used during the scan. The 
inquest heard evidence that a CT scan should have been undertaken and there was 
no need to wait for blood test results. This raised a concern that staff at the Trust are 
unaware of this guidance. 

 
 
 
 
 
 
 
 
  
 
 
 
 1.         Volume of patients presenting to the Emergency Department 

This area of concern is for the Department of Health and Social Care however we 
acknowledge that there has been a significant increase in demand for assessment by 
the Emergency General Surgery (EGS) Service at UHB. This was the service to 
which Mrs Thomas was appropriately referred by the Emergency Department. In this 
case failure of assessment and escalation occurred after this referral. She was seen 
by the EGS service at 11:30am by an experienced Specialist Registrar (SpR) who 
was in the 7th Year of specialist training (ST7). When that SpR returned at 20:00 Mrs 
Thomas, after waiting for so long, had taken her own discharge. We acknowledge 
that Mrs Thomas had to wait far too long and that this was a failure of the EGS 
service. It has not been possible to establish why Mrs Thomas was not escalated to a 
consultant at the time of her presentation, or after it was found that she had self-
discharged. It is the case that the service has been increasingly busy following the 
resolution of the pandemic. Although it is not possible to directly link the level of 
demand on this day to individual decision making, a response to increasing demand 
for surgical review is a matter which UHB recognises as a risk and to which the trust 
is responding.  

These responses include:  

  Provision of two dedicated consultants to manage the emergency surgical 

patients on the Birmingham Heartlands and Queen Elizabeth sites. These two 
consultants are freed from any elective activity when on call.  

  The appointment of specialised Emergency General and Trauma Surgeons at 

the Queen Elizabeth Site.   

  The creation of a virtual ward, managed by new specialist nurses, so that 

emergency patients can be managed on an ambulatory basis. This has saved 
over 1000 bed days this year and reduced the workload for the junior doctors 
on the QE site. This will be expanded to the Trust’s other acute sites by 31 
October 2023. 

  Expansion of the EGS service by another two consultants by the end of 2023. 

This expansion will support the initiation of so called ‘Hot clinics’ for the 
expedited review of ambulatory patients. This will allow patients to bypass the 
Surgical Admissions Unit (SAU) and thereby reducing the load on junior 
doctors working in that area and the Emergency Department. It will lead to 
improved patient experience and reduce the number of patients in ED and 
SAU, allowing those units to focus on caring for the more unwell patients.  

 2.        Risk stratification 

In June 2016, the Royal College of Emergency Medicine (RCEM) identified high-risk 
groups of patients who should be reviewed by a consultant in Emergency Medicine 
before they are discharged from the Emergency Department. 

2 

 
 
  The patient groups were: 

i.          Atraumatic chest pain in patients aged 30 years and over;  

ii.          Fever in children under 1 year of age;  

iii.         Patients making an unscheduled return to the ED with the same condition 

within 72 hours of discharge; and,  

iv.        Abdominal pain in patients aged 70 years and over.  

Mrs Thomas clearly fell into both category iii and iv so should have been reviewed by 
a consultant.   In this case Mrs Thomas had been appropriately referred to the on call 
General Surgery team. It was therefore incumbent on the General Surgery team to 
make an appropriate assessment and formulate a diagnostic and treatment plan 
which would have included consultant review. This was not done. If Mrs Thomas’s 
CT scan had been carried out immediately then she would have been admitted to 
SAU and subsequently reviewed by the EGS consultant on the ward round later that 
day. In this case, Mrs Thomas had to wait an unacceptably long time for repeat 
review, she therefore self-discharged and therefore without consultant review. The 
lack of consultant review was an effect of the delay in her being identified as 
requiring consultant review by the SpR at the time of assessment and later in the 
day. This is a single point of failure which, as previously mentioned, may have been 
exacerbated by workload.  

The lack of consultant review will be mitigated by the increased provision for the EGS 
services which will reduce the workload on the junior doctors but this case also 
identifies a deficiency in policy.  

On the second presentation it should have been clear that Mrs Thomas required 
admission and while this may always have been the intention of the assessing 
surgical SpR, this decision was delayed waiting for blood results and a CT scan. This 
is the aforementioned single point of failure.  

The Trust has therefore implemented a new policy developed by the Clinical Service 
Leads for EGS and ED, alongside a programme of education (from August 2023) in 
which any member of the multi-professional team are invited to escalate concerns 
regarding delayed assessment, or delayed transfer of patients to SAU, to the 
consultant on call. This will be enhanced by a communication strategy that will 
include direct teaching and laminated posters displayed in acute surgical areas at all 
acute sites (by 31 October 2023). This communication will emphasise the importance 
of this action for patient safety and will not be a punitive action.  

In this case where Mrs Thomas had not been “accepted” by EGS, any ED healthcare 
professional would be empowered to escalate this to the EGS consultant.  

3.         Emergency CT scans and the use of Intravenous Iodinated Contrast Agents 

Computed Tomography (CT) scanning is an important diagnostic modality in patients 
with acute abdominal pain and the use of intravenous iodinated contrast agents 

3 

 
  
 
 
 
 
 
 significantly enhances the diagnostic accuracy of CT scans. For many years, 
knowledge of functional renal status (as documented by blood test results) has been 
required prior to giving iodinated contrast agents. 

Modern contrast agents are much safer than older agents and studies have reported 
that blood tests are not required for emergency CT scans. In June 2023, the Royal 
Colleges of Radiologists & Royal College Emergency Medicine published joint 
guidance, strengthening previous guidance, that patients requiring emergency 
iodinated intravenous contrast CT imaging should proceed to scanning without delay. 
The Trust will ensure that relevant staff are aware of this guidance and will ensure 
that it is disseminated to all staff managing acute surgical emergencies.             

Following Mrs Thomas’s death the following actions are being taken to share the learning 
from this incident: 

1.  Locally: Laminated posters of the joint statement will be displayed in acute surgical 

areas at all acute sites. A new trust policy that directly reflects the June 2023 
guidelines will be published and disseminated to all clinical staff. The Trust will 
update online requesting system to reflect the new guidance. This will be discussed 
at all relevant departmental governance meetings. These actions will be completed 
by 31st October 2023. 

2.  Regionally: The Trust will engage with the West Midlands Postgraduate School of 
Surgery to ensure all General Surgical speciality trainees are informed of the 
updated guidance. It is anticipated that this will be within the induction programme 
and will be included in literature provided to junior doctors. 

3.  Nationally: The Trust will report this incident to the Confidential Reporting System in 

Surgery (CORESS). 

I would like to reassure you that the concerns raised within the Regulation 28 Report have 
been taken extremely seriously which I hope is demonstrated by our response above. 

Yours sincerely 

Chief Medical Officer 

CC: 

, Chief Nurse 

 - Green, Chief Nurse and Deputy Chief Operating Officer, ICB 
, Chief Medical Officer, ICB 

, Head of Clinical Governance and Patient Safety 

4

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

Louise Hunt  
Senior Coroner for Birmingham and Solihull 
Coroner's Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

12 April 2024  

Dear Ms Hunt, 

Thank you for your letter of 28 June 2023 to the Secretary of State for Health and Social Care 
about  the  death  of  Mrs  Hilary  Thomas.  I  am  replying  as  I  am  replying  as  Minister  with 
responsibility  for  Urgent and Emergency  Care.  Please  accept  my  sincere  apologies  for the 
delay in responding to this matter. I would like to assure you that the Department is mindful of 
the  statutory  responsibilities  in  relation  to  prevention  of  future  deaths  reports  and  we  are 
prioritising responses as a matter of urgency.  

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mrs Thomas’ 
death and I offer my sincere condolences to her family. I am grateful to you for bringing these 
matters to my attention. 

Your  report  raised  concerns  about  the  capacity  of  Birmingham  Heartlands  Hospital  to  deal 
with the volume of patient attendances. I note that the University Hospitals Birmingham NHS 
Foundation  Trust  has  written  to  you  separately.  The  trust’s  response  acknowledges  the 
emergency  general  surgery  service  has  become  increasingly  busy following  the  pandemic.  
The  trust  has  set  out  the  specific  actions  they  are  taking  locally  to  increase  capacity  and 
resources to manage the increased volume of patient attendances.  This includes the provision 
of additional consultant resource. 

I  recognise  the  pressures  A&E  departments  are facing  and the  impact  of  waiting  times  for 
patients. In January 2023 we published our ambitious Delivery plan for recovering urgent and 
emergency  care  services  to  drive  sustained  improvements  in  urgent  and  emergency  care 
waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients 
to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to 
reduce Category 2 ambulance response times to 30 minutes across this fiscal year.  

A  key  part  of  the  plan  has  been  to  increase  hospital  capacity  to  improve  patient  flow  and 
reduce  overcrowding  in  A&E.  We  achieved  our  2023/24  ambition  of  delivering  5,000  more 
staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion 
of  dedicated  funding,  and  we  will  maintain  this  capacity  uplift  in  2024/25.  Further,  we  also 
achieved our target  of  scaling  up  virtual  ward  bed  capacity to  over  10,000  ahead of  winter 
2023/24,  and there  are now  over  11,000  beds available nationally.  We  also have provided 
£1.6 billion of funding over two years to support the NHS and local authorities to ensure timely 
and effective discharge from hospital.   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We  have  seen  improvement  in  A&E  waiting  times  this  year  following  the  Delivery  plan’s 
publication, however we recognise there is more to do, and reducing waiting times is a priority 
for this Government. 

I  hope this response  further reassures  you of  the  work  undertaken.  Thank you  for  bringing 
these concerns to my attention.  

Yours,  

HELEN WHATELY