Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0390, written 17 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Oct 2023 |
|---|---|
| Reference | 2023-0390 |
| Deceased | Holly Mullan |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| Organisation named | Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England 1 CORONER I am Alison Mutch, HM Senior Coroner, for the coroner area of South Manchester 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 9th May 2023 I commenced an investigation into the death of Holly May Mullan. The investigation concluded on the 29th September 2023 and the conclusion was one of Narrative: Died from the complications of suspension from a ligature whilst under the influence of alcohol. The medical cause of death was 1a) Hanging 4 CIRCUMSTANCES OF THE DEATH Holly May Mullan had longstanding severe abdominal pain. She had long delays waiting for medical appointments to see gynaecologists and gastroenterologists due to long waiting lists. At times she accessed private consultations to try and obtain insight into and relief from her pain. On 7th May 2023 Holly May Mullan was found at 3 Napier Road attached to a ligature. Police enquiries found no suspicious circumstances and no evidence of third-party involvement. Post-mortem examination found she was significantly under the influence of alcohol at the time of her death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest heard evidence of the distress caused to Holly and the impact on her health by the long waits to be seen by gastroenterologists and gynaecologists within the NHS. The evidence heard was that post- Covid, the waiting times to be seen in both specialities unless the referral 1 was on the two-week cancer wait had grown significantly across England. As an illustration the inquest was told that pre-Covid, the average wait for a routine gynaecology referral was 18 weeks. Now in England the wait was often in excess of 12 months. Even an urgent referral would often involve a wait of over 40 weeks. This was leading to delays in diagnosis and treatment even in those with significant/severe health conditions. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th December 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following on behalf of the Family Interested Persons namely 1) and; 2) Stockport NHS Foundation Trust, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 17.10.2023 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Alison Mutch
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
4 December 2023
Re: Regulation 28 Report to Prevent Future Deaths – Holly May Mullan who died
on 7 May 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17
October 2023 concerning the death of Holly May Mullan on 7 May 2023. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Holly’s family and loved ones. NHS England are keen to
assure the family and the coroner that the concerns raised about Holly’s care have
been listened to and reflected upon.
In your Report you raised the concern that following the COVID-19 pandemic, waiting
times for gastroenterologist and gynaecologist had grown significantly across
England. NHS England Women’s Health and Gastroenterologist professionals have
been sighted on your Report and have contributed to this response.
The Delivery Plan for Tackling the COVID-19 Backlog of Elective Care sets out plans
to reduce waiting times and improve patient experience for patients across all specialty
areas, including gynaecology and gastroenterology.
NHS England are also implementing the national rollout of the Getting it Right First
Time (GIRFT) Programme, which is designed to improve the treatment and care of
patients through reviews of services, benchmarking and developing an evidence base
to support change. Through the High Volume Low Complexity programme, the GIRFT
team is working with health systems and regions across England to help the NHS
recover performance in elective services and reduce the backlog of patients.
Gynaecology is one of six specialties being prioritised through this programme, which
supports the establishment of surgical hubs for high-volume procedures and the
development of standardised patient pathways. The GIRFT programme will work with
the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider
how surgical hubs can work in gynaecology as a specialty.
The GIRFT Further Faster Programme is also specifically looking at eradicating long
waiting times from referral to treatment (RTT), in 16 different specialties. The
specialties of Gastroenterology and Gynaecology both involved in the Further Faster
Programme and have made good inroads into reducing long RTT waiting times in the
first cohort of Further Faster Trusts (25 Trusts taking part), compared to the non-further
faster Trusts. Of the 16 specialties involved in this programme, gastroenterology has
trusts’
shown
(39% difference, as non-further
the greatest
impact
faster
gastroenterology numbers of 52+ week waiters increased by 122% by October 2023
with Further Faster Trusts reducing these to 83% of the starting figure from July 2023).
The Programme has rolled out to a second cohort of 25 Trusts in November 2023 and
will be disseminating lessons learned across the wider NHS.
As part of the further NHS response to COVID-19, NHS England introduced the
Clinical Prioritisation Programme. This sets out an expectation of clinical review of
waiting lists, to enable patients with the most urgent conditions to be reviewed first
based on the information available (such as urgency indicated at referral or decision
to admit, procedure type, specialty, and length of time that the patient has been waiting
for treatment). The guidance was developed with the Academy Of Medical Royal
Colleges.
It is not clear from your Report or from subsequent questions to your office if Holly
received any diagnosis for the pain she was experiencing or if she was eventually
seen by NHS gynaecologists or gastroenterologists. If she was not on an admitted
waiting list, but instead waiting for outpatients service her referral should have been
triaged, although NHS England are not able to investigate this without further
particulars. You may wish to contact the Trust to obtain further information.
The NHS is changing how it delivers outpatient services so that patients can be seen
more quickly and can access and interact with services in a way that better suits them.
We are giving patients and carers more control and greater choice over how and when
they access care. We have recommended more use of patient initiated follow up
(PIFU) pathways, which help empower patients to book their own follow-up care as
and when they need it. We are encouraging services to discharge patients as soon as
this is appropriate, with safety net advice, to reduce unnecessary follow up
appointments. This allows those patients who do need to access appointments to be
seen more quickly. We are helping services to reduce the number of missed outpatient
appointments (did not attends or DNAs) to make the best use of all available
appointments.
As part of outpatient transformation, we are encouraging and enabling access to
earlier expert advice through triage of referrals and by greater use of advice &
guidance (A&G) or advice & refer (A&R) services. This allows patients and GPs to get
the benefit of expert advice and treatment much earlier in the patient pathway. Patients
who do not need to be seen in outpatients can continue to be safely managed in
primary care, following specialist advice, or may be diverted direct to test where
appropriate to facilitate an earlier diagnosis. This allows those that do need to be seen
in clinic to get access to clinic in a much shorter timescale and will help reduce referral
to treatment times for all patients.
I would also like to provide further assurances on national NHS England 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
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