Marianne Erika

Alison Mutch 
Senior Coroner  
Greater Manchester South  
Coroner’s Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG  

Dear Coroner, 

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

11 September 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Marianne Erika Oldham 
who died on 17 December 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 July 
2023 concerning the death of Marianne Oldham on 17 December 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Marianne’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the coroner that the concerns raised about Marianne’s care have 
been listened to and reflected upon.  

In your Report you raised concerns over the demands being placed on Emergency 
Departments (EDs) and the delays this was causing to triaged patients being seen by 
clinicians, particularly during the winter period. You also raised the concern that delays 
were being compounded by a shortage of radiographers and radiologists.  

NHS  England  recognises  the  significant  pressure  on  ambulance  services  since  the 
Covid-19 pandemic, which has seen longer response times across all ambulance call 
categories than before the pandemic, as well as issues associated with handing over 
ambulance patients in a timely way including the flow of patients in and out of some 
NHS  Trusts.  That  is  why  NHS  England  are  focusing  on  improving  ambulance 
performance  for  2023/24,  supported  by  the  Delivery  plan  for  recovering  urgent  and 
emergency care services, published in January 2023.  The plan outlines the actions 
and  steps  that  we  are  taking  across  England  to  recover  and  improve  urgent  and 
emergency  care  (UEC)  services,  including  improving  ambulance  response  times, 
increasing ambulance capacity through growing the workforce, improving flow through 
hospitals,  speeding  up  discharges  from  hospitals,  expanding  new  services  in  the 
community,  and  taking  steps  to  tackle  unwarranted  variation  in  performance  in  the 
most challenged local systems. 

In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and 
Primary  Care  Networks  titled  Delivering  operational  resilience  across  the  NHS  this 
winter. This includes focusing on reducing waiting times for patients and crowding in 
A&E departments, improving flow, and reducing length of stay in hospital settings.   

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Nationally, there are clear requirements placed on NHS Trusts to ensure that the right 
skill  mix  of  medics  and  other  professional  groups  are  in  place  to  respond  to  the 
anticipated  demand  throughout  a  day.  This  includes  the  expectation  that  senior 
decision makers are available to support more junior doctors and that diagnostics can 
occur in line with best practice and clinical standards set by the National Institute for 
Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. 
It is, however, acknowledged that resourcing remains an issue across the NHS, with 
local services reporting over 112,000 vacancies. In June this year, the NHS published 
its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a 
sustainable footing over the next fifteen years to improve patient care. The plan sets 
out three core priorities; to improve training and education, ensure that we retain more 
staff, and to reform. The plan is underpinned by the biggest recruitment drive in NHS 
history.   

NHS England has also engaged with the Greater Manchester Integrated Care Board 
(GM ICB) regarding your concerns about Marianne’s care. Within Greater Manchester, 
and  at  Tameside  General  Hospital,  demand  on  the  Emergency  Department  was 
exceptionally  high  at  the  time  of  Marianne’s  attendance.  Patients  were  seen  and 
assessed in clinical priority order to ensure that the most acutely unwell patients were 
given priority. The department had to utilise escalation areas which meant caring for 
nine patients on the corridor and they were experiencing ambulance handover delays. 
There were no gaps in the medical workforce and one Registered Nurse gap on the 
night  shift.  All  Greater  Manchester  acute  providers  reported  being  at  Operational 
Pressures Escalation Levels Framework (OPEL) level 3 (the health and social care is 
experiencing  major  pressures  compromising  patient  flow)  during  the  week  of 
Marianne’s death.  

Attendances at Type 1 Emergency Departments are significantly higher in the winter 
months than in the summer months, and the usual winter pressures were compounded 
during the week commencing 12th December 2022 by particularly cold weather with 
snow  in  some  areas  and  an  increase  in  influenza-type  illnesses  compared  to  the 
previous two years and an increased acuity of patients leading to longer lengths of 
stay for patients.  

A deep dive was undertaken into urgent care by the Greater Manchester Integrated 
Care Quality and Performance Committee in January 2023. Deep dives present an 
opportunity  for  quality  and  performance  teams  to  work  with  system  boards  and 
provider  partners  to  set  out  the  key  deliverables,  challenges,  risks,  and  impact  on 
safety  in  relation  to  a  specific  service  as  well  as  provide  an  update  against 
improvement  programmes  and  plans.  To  inform  this  deep  dive,  a  wide  range  of 
information. 
intelligence  was  reviewed 
Qualitative information reviewed included but was not limited to learning from reports 
to prevent future deaths and serious incidents, complaint themes, and the friends and 
family test.  

including  quantitative  and  qualitative 

 
 
 
 Further information on this deep dive can be found here: gmintegratedcare.org.uk/wp-
content/uploads/2022/12/gm-quality-and-performance-committee-january-2023-
public-meeting-pack.pdf. 

There is a 15% vacancy rate across Greater Manchester of radiologists at consultant 
grade. The GM Imaging Network are supporting the upskilling and change of skill mix 
within  the  imaging  workforce  by  allocating  funding  for  reporting  radiographers, 
focusing on computerised tomography (CT) and magnetic resonance imaging (MRI) 
reporting  radiographers.  Furthermore,  the  Network  are  coordinating  international 
recruitment  via  a  Clinical  Diagnostic  Centre’s  funding  stream  to  bring  in  more 
radiologists.   

The Imaging Network are exploring the use of a collaborative staff bank, including CT, 
to  reduce  reliance  on  third  parties.  The  future  introduction  of  Picture  and 
Communication Systems (PACS) based reporting will also be an enabler for a more 
centralised service to be used for reporting.  PACS provide economical storage and 
convenient access to images from multiple modalities and could therefore be used as 
central storage systems that can be used across GM, reducing the staffing resource 
required for reporting.  The implementation of PACS is currently a key scheme within 
GM’s Imaging Digital Programme. 

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