Carol Leeming

From Will Quince MP 
Minister of State for Health and Secondary Care 

39 Victoria Street 
London 
SW1H 0EU 

Christopher Morris  
HM Area Coroner   
Coroner’s Court 
1 Mount Tabor Street  
Stockport, SK1 3AG 

Dear Mr Morris,  

 28th August 2023 

Thank you for your letter of 4th November 2022 about the death of Lynn Moss. I am replying 
as Minister with responsibility for Health and Secondary Care, and thank you for the additional 
time allowed.    

Firstly, I  would like to say  how  saddened  I  was  to read of  the circumstances of Mrs  Moss’ 
death and I offer my sincere condolences to her family and loved ones.  The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention.  

In preparing this response, Departmental officials have made enquiries with NHS England as 
well as the regulation in this instance, the Care Quality Commission. 

Sepsis  can  be  a  devastating  condition  and  patients  rightly  expect  the  NHS  to  be  able  to 
recognise and diagnose it early and provide the highest quality treatment and care.  

Over recent years, the NHS has become much better at spotting and treating sepsis quickly.  
This means that more people are being identified as at risk of sepsis and mortality rates are 
falling. However, we know that some patients who deteriorate with sepsis are still not being 
diagnosed quickly enough.   

In  April  2018,  a  National  Early  Warning  Score  patient  safety  alert  was  issued  to  support 
providers to adopt the revised National Early Warning Score (NEWS2) to detect deterioration 
in adult patients, including those with suspected sepsis1. However, there is an opportunity for 
sepsis  guidance  to  be  improved  to  ensure  appropriate  room  for  diagnostics  and  clinical 
judgement  in  the  recognition  and  treatment  of  deterioration,  including  from  sepsis. 

In response to growing evidence of the need to update sepsis guidance and provide a stronger 
framework for treatment of deterioration, the Academy of Royal Medical Colleges (AoMRC), 
in partnership with the Faculty for Intensive Care Medicine, published their ‘Statement on the 
initial antimicrobial treatment of sepsis’ in May 20222. 

1 Patient_Safety_Alert_-_adoption_of_NEWS2.pdf (england.nhs.uk) 
2 Statement_on_the_initial_antimicrobial_treatment_of_sepsis_0522.pdf (aomrc.org.uk)  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 To support a strong understanding of new guidelines for recognition and treatment of sepsis 
amongst  a  wide range  of  healthcare  professionals,  NHS  England is  working  to  ensure  that 
clinical staff caring for patients will have access to appropriate education, including through 
new learning tools and additional materials on HEE’s website3. 

The National Institute for Health and Care Excellence (NICE) also launched a consultation to 
seek views on updating its guidance on the recognition, diagnosis and early management of 
suspected  sepsis.  The  consultation  ran  from  7  to  21  December  and  updated  guidance  is 
expected to be published in 20234. 

We recognise the pressures the ambulance service is facing which is why we published our 
delivery plan for recovering urgent and emergency care services. This aims to deliver one of 
the fastest and longest sustained improvements in waiting times in the NHS's history reducing 
Category 2 response times to 30 minutes this year, with further improvements towards pre-
pandemic levels next year.   

Ambulance services are receiving £200 million of additional funding this year to grow capacity 
and  improve  response  times  alongside  800  new  ambulances,  including  specialist  mental 
health ambulances.  Backed by nearly £50 million, the delivery of 6 new ambulance hubs and 
42 new or upgraded discharge lounges will cut unnecessary delays, helping get ambulances 
back on the road faster.  

To  increase  hospital  capacity  and  reduce  waits,  the  delivery  plan  will  deliver  5,000  more 
staffed, permanent beds this year compared to 2022-23 plans, backed up £1bn of dedicated 
funding. This is alongside £1.6 billion over the next 2 years to reduce the numbers of beds 
occupied  by  patients  ready  to  be  discharged  helping  improve  flow  through  hospitals  and 
reducing ambulance handover delays.  

Ambulance  trusts  receive  continuous  central  monitoring  and  support  from  the  National 
Ambulance Coordination Centre. Furthermore, the 24/7 System Control Centres established 
across all local NHS systems last winter are enabling year-round use of real-time data and 
local insights to better manage demand and respond to emerging challenges at a system level.  

Further, the NHS has expanded falls response services right across the country, where local 
community teams are sent to help people who have fallen in their home or in care homes, 
saving vital ambulance resource and unnecessary trips to hospital. 

To  build  capacity  in  social  care  ahead  of  this  winter,  we  will  launch  the  next  phase  of  our 
National Recruitment Campaign to encourage more people to join social care. We are also 
boosting international recruitment of care workers, with a further £15 million invested this year 
and more next year.  

Finally, in primary care, we have already committed to invest at least £1.5 billion to create an 
additional 50 million general practice appointments by 2024, by growing and diversifying the 
workforce, which should improve access for patients. We estimate that this plan will deliver 
over a million more appointments this winter by bolstering general practice teams with other 
professionals  who  can  help  them.  This  will  reduce  the  need  for  A&E  and  emergency  care 
getting patients the treatment where they need it.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

3 https://www.hee.nhs.uk/our-work/sepsis-awareness  

4 https://www.nice.org.uk/guidance/indevelopment/gid-ng10310  

 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely,  

Minister of State Health and Secondary Care

Totally 
Cardinal Square West 
10 Nottingham Road 
Derby 
DE1 3QT 

Ms Georgina Nolan 
HM Senior Coroner 
Newcastle upon Tyne & North Tyneside Coroner’s Court 
Civic Centre 
Barras Bridge 
Newcastle Upon Tyne 
NE1 8QH 

Date 22/12/2023 

Dear Ms Nolan 

Thank  you  for  the  regulation  28  prevention  of  future  deaths  report  sent  to  Vocare  following  the 
inquest of Mrs Carol Leeming. 

Vocare has prioritised our investigation into the issues raised in your report, and we set out below our 
responses to the concerns you raised which are: 

(1) There was no requirement for the out of hours GP to have completed induction training prior to 
starting work for Vocare; 
(2) There was no facility for online induction training to be made available to new joiners who were 
unable to attend in person induction training; 
(3)  There  was  evidence  of  confusion  amongst  staff  about  the  functioning  and  capabilities  of  the 
systems in place at the call centre; and 
(4) Evidence was given at the inquest that there was a regular turnover of different GPs working for 
Vocare for short periods as part of their training. 

We note your acknowledgment in your inquest conclusion that the above concerns did not affect the 
outcome for Mrs Leeming, as the conclusion of the inquest was natural causes, the medical cause of 
death being 1a) Coronary artery atheroma; 2) Chronic Obstructive Pulmonary Disease. 

Vocare is an established urgent care provider managing GP out of hours services across the North East 
and Wearside areas, Yorkshire and Staffordshire as well as managing urgent treatment centres from 
Berwick to Selby and including the Staffordshire regions. It also provides NHS 111 service for areas of 
the  South  East  and  London  and  also  in  Staffordshire.  The  service  is  continually  scrutinised  by  our 
commissioners as well as the CQC which regulates the organisation, to ensure that patient safety is 
paramount. Key to this is the ability, expertise and welfare of our staff. The service we offer is in line 
with  the  NHS  England  Integrated  urgent care  service  specification [2017,  updated  2023]  regarding 
inter alia, the national expectations for the management and prioritisation of ambulance calls, and 
the defined interoperability standards for interservice transfers. 

To ensure that staff are fully trained the following systems are in place: 

1.  There was no requirement for the out of hours GP to have completed induction training prior 

to starting work for Vocare; 

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 Totally 
Cardinal Square West 
10 Nottingham Road 
Derby 
DE1 3QT 

Although it was a requirement for the GP trainee to attend the induction, no alternative dates were 
offered to him in spite of his repeated requests. Induction sessions were run 6 monthly in line with 
the GP trainee  intakes. However,  inductions are now being run quarterly  so  GP trainees have  two 
options  to  attend  the  course  and  should  not  be  in  a  position  where  they  have  not  attended  an 
induction prior to working for the organisation. If they cannot attend then they do not work for us. 
They do their urgent care training in in-hours surgeries and not in the out of hours period with Vocare. 
Induction is a pre-requisite to work. The administrative team takes a register of who is at induction 
and only these doctors are given shifts to work. 

In addition, following feedback from the attendees it has been agreed that the induction sessions will 
be run in bite-sized sessions to increase their usefulness.  Thus, the induction is divided into 6 slide 
shows with breaks in-between. The induction covers IT systems and operational matters, thus giving 
clinicians the tools, they need to ensure that safe high-quality care is delivered. 

2.  There was no facility for online induction training to be made available to new joiners who 

were unable to attend in person induction training; 

Once an individual has completed the physical induction training, there is a facility for the knowledge 
base online training which reinforces the induction material currently in place via the organisational 
intranet. However, GP trainees do not obtain access to the intranet until they are provided with their 
log in details on commencement of their placement. It is anticipated that this online material will be 
an  adjunct  to  the  more  frequent,  and thus more  accessible  personal  induction  sessions  which  will 
preclude any starter from commencing work with the organisation where they have not attended a 
physical induction. 

3.  There was evidence of confusion amongst staff about the functioning and capabilities of the 

systems in place at the call centre; 

Although it is recognised that there is now full interoperability between services in the North East via 
the use of the PACCs system, there  is always the chance  that it may  fail. All staff have  undergone 
refresher training and are therefore aware of the business continuity plan should this happen. Posters 
are in situ and reminders have been placed on individual desk tops as an adjunct to this.  An improved 
process for supporting the GP supervisors is in place such that all supervisors fully understand their 
responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is 
acknowledged that the organisation works collaboratively with the Deanery in this regard. 

4.  Evidence was given at the inquest that there was a regular turnover of different GPs working 

for Vocare for short periods as part of their training. 

The organisation has two intakes of 30 GP trainees a year. The GP trainees complete 24 hours of work 
with us in addition to their 6 hours induction and training. This is a block of training and is done within 
3 months.  A further block of 24 hours is undertaken within the next 3 months which may be with 
Vocare or with another provider.  Feedback from trainees is positive and many apply to join our team 
when they qualify.  The organisation exposes them to many urgent care cases, palliative care cases 
and give them an understanding of the urgent care system at large. 

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 Totally 
Cardinal Square West 
10 Nottingham Road 
Derby 
DE1 3QT 

As an organisation we continually learn and improve our service in tandem with our co providers at 
North East Ambulance Service. 

More broadly, Vocare has robust clinical governance processes in place which identify incidents of 
concern and ensure actions are taken to reduce risk of recurrence. The North East and North Cumbria 
Integrated Care Board (ICB) with whom we work closely, has oversight of the governance processes. 

We hope the above gives you assurance that we have and continue to take these issues very seriously. 
Vocare has effective systems in place to reduce the risk of similar issues recurring by improving our 
induction, ongoing training and supervision and mentoring of our GP trainees and also any new GP to 
the  organisation.  We  are  not  complacent,  and  we  continually  review  our  processes.  We  will  be 
cognizant  of your report when developing and reviewing our pathways to ensure the current high 
standards are continually maintained. 

Yours sincerely 

Head of Corporate Assurance 

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