Kathleen Booth

Emma Serrano  
Staffordshire & Stoke-on-Trent  
Coroner’s Chambers 
547 Hartshill Road 
Hartshill 
Stoke-on-Trent 
ST4 6HF  

Dear Coroner, 

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

t  
16th January 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Kathleen Booth who died 
on 13 June 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  22 
November 2023 concerning the death of Kathleen Booth on 13 June 2023. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Kathleen’s family and loved ones. NHS England are keen to 
assure the family and the coroner that the concerns raised about Kathleen’s care have 
been listened to and reflected upon.  

Your Report raises the concern over under staffing and under funding of NHS services 
and  that  the  fact  that  the  injury  happened  on  a  weekend  meant  less  staff  and 
experience were available for Kathleen’s care and treatment.  

In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which 
introduced clinical standards regarding the provision of a “truly seven-day NHS” and 
requiring  acute  trusts  to  provide  board  assurance  compliance.  The  Programme 
focuses on the provision of acute medical care in such a way that there is no difference 
in quality for patients, whether it is a weekday or a weekend. There is a good level of 
compliance with these standards across acute trusts and many services and surgical 
and diagnostic lists are operating at weekends and evenings.  

In January 2023, NHS England published the Delivery plan for recovering urgent and 
emergency  care  services.  This  is  a  two-year  delivery  plan  which  sets  the  NHS 
commitment  to  the  public  to  improve  waiting  times  and  patient  experience  within 
urgent and emergency care (UEC). This includes commitments to:  

1.  Increase  capacity  (to  include  dedicated  funding  of  £1  billion  for  additional 

capacity, including 5,000 new beds). 

2.  Grow the workforce, including introducing more flexible ways of working. 
3.  Speed up discharge from hospitals.  
4.  Expand new services in the community, as up to 20% of emergency admissions 

can be avoided.  

5.  Help people access the right care first time.  

In  June  2023,  NHS  England  also  published  the  NHS  Long  Term  Workforce  Plan, 
setting out how it will train, retain and reform its workforce across the next fifteen years 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to  ensure  that  we  are  improving  access,  providing  safe  and  timely  urgent  and 
emergency  care  and  continuing  to  reduce  elective  care  backlogs.  The  Plan  is 
underpinned by the biggest recruitment drive in NHS history.     

Elective care recovery also continues to be a priority for the NHS. In February 2023 
the Delivery plan for tackling the Covid-19 backlog of elective care was published by 
NHS  England.  This  focused  on  four  areas  of  delivery  to  increase  health  service 
capacity, prioritise diagnosis and treatment, transform how we provide elective care 
and  provide  better  information  and  support  to  patients.  This  is  supported  by  a 
government spend of more than £8 billion between 2022/23 and 2024/25, including a 
£5.9  billion  capital  investment  in  new  beds,  equipment,  and  technology.  Further 
priorities were set out in a letter to NHS acute Trusts in May 2023, which can be found 
here: NHS England » Elective care 2023/24 priorities.  

The NHS continues to encourage local health systems to develop effective workforce 
planning  to  ensure  that  they  have  the  sufficient  qualified  staff  working  across  their 
Trusts and wider system that are required for their population care needs. The NHS 
People Promise also helps NHS providers to consider ways to recruit and retain staff. 
Work is in progress to ensure that future distribution of training posts to help ensure 
the  supply  of  doctors  is  matched  to  population  need.  You  will  need  to  refer  to 
Staffordshire  and  Stoke-on-Trent 
Integrated  Care  System  on  what  system 
arrangements they have in place for their UEC provision and workforce. 

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

Executive Suite 
Trust Headquarters 
Springfield 
City General Site 
Newcastle Road 
Stoke on Trent 
ST4 6QG 

22 January 2024 

STRICTLY PRIVATE & CONFIDENTIAL 
Mrs Emma Serrano  
H M Area Coroner  
Stoke on Trent and North Staffordshire 

Dear Mrs Serrano  

Kathleen BOOTH  

Further to your letter dated 22 November 2023, I am pleased to provide a response under paragraph 7 of 
Schedule  5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroner’s 
(Investigations) Regulations 2013, addressing your concerns surrounding the death of Kathleen BOOTH.  

Recorded Circumstances of the Death 
Mrs Booth was admitted to hospital as an emergency following a fall in her own garden on Friday 9 June 
2023. She was transported by ambulance to the Royal Stoke University Hospital, Stoke on Trent. Hip x-
rays confirmed a displaced intra-capsular neck of femur fracture on the left. 

On admission, Mrs Booth was taking Apixiban, an anticoagulant medication, that required stopping for 24 
hours before any surgery could be.  

Provisional plans were made to carry out surgery over the weekend when able to do so, considering her 
anticoagulation.  

Between 9 June and 12 June, we had many trauma admissions requiring emergency surgery and over the 
weekend of 10 June and 11 June 2023 we surgically treated 21 trauma cases. These included 3 Paediatric, 
3  Spines  and  15  Orthopaedic  cases  and  some  very  complex  cases  within  that.  Under  exceptional 
circumstances  such  as  this  it  means  that  cases  have  to  be  clinically  prioritised,  i.e.  those  requiring 
emergency treatment were managed first before less urgent cases. This inevitably meant that some cases 
were postponed.  

On Monday 12 June 2023, a decision was made to operate but was delayed to the following day due again 
to a large amount of trauma patients in the hospital. On 13 June 2023, the surgery was performed and was 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
    
 
 
 
 
 
 
 
 
 
 
 
 
 uneventful. After surgery Mrs Booth was found to be alert and comfortable in the recovery area. Around 
9pm, she suffered a sudden deterioration and passed away. 

Concerns 
During the course of the inquest you felt that evidence revealed matters giving rise for concern. The issues 
raised were: 

1.  There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; 
and wards having to undertake elective and emergency work at the same time. Additionally, the fact 
that the injury happened on a Friday, meaning less staff and experience was available.  

2.  Earlier intervention is associated with better outcomes. 

3.  Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover 

over the weekend is limited.  

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  

In your opinion, action should be taken to prevent future deaths.  

Action Taken 
The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest 
seriously and indeed, I am grateful that you have raised your concerns. 

1.  UHNM is a major trauma centre (MTC) and provides a very high quality service for a population of 
over three million.  As a MTC the trust is required and does have the ability to perform major trauma 
surgery 24 hours a day, seven days a week for all days of the year.  There are exceptional occasions 
when demand outstrips capacity, and these cannot always be foreseen or planned for.  However, 
when they occur the management teams work with the clinicians to review job plans and reallocate 
work to ensure the urgent and emergency patients get seen as soon as possible. 

It  is  acknowledged  that  there  was  a  delay  of  4  days  between  presentation  on  9  June  2023  and 
surgery being undertaken on the morning of 13 June 2023. However, as Mrs Booth was on Apixaban 
for AF the very earliest she could have undergone surgery was 24 hours later on the morning of 10 
June 2023, as the last dose of Apixaban was on the morning of 9 June 2023. Mrs Booth would have 
been optimal for surgery within 24-36 hours of coming off Apixaban and a 24-36 hour delay for Mrs 
Booth would have been clinically appropriate.  

Please see the response to question 3 regarding weekend cover and access to services.  

2.  It  is  agreed  that  earlier  intervention  is  associated  with  better  outcomes  for  patients  requiring 
emergency (and urgent) surgery following injury. As a Trust with a significant major trauma unit, we 
endeavour to treat patients with a fragility fracture within 36 hours of presentation where clinically 
appropriate. However, the data within the NHFD (National Hip Fracture Database) does not link a 
delay in theatre with an increased risk of mortality.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 However, the trust does annually review capacity and demand for all its services and based on one 
of these reviews and subsequent business case, on the 6 November 2023, the Trauma Directorate 
introduced a dedicated fragility fracture theatre list, 5 days per week.  This has seen a reduction in 
time to theatre for this cohort of patients since its inception. Capacity and demand also include the 
weekend provision and the division are preparing a business case to see if the demand over the 
weekend period requires the same on a Saturday also.  

3.  Routinely,  over  the  weekend  there  is  provision  for  2  all-day  trauma  theatre  lists  which  provides 
shared theatre capacity for orthopaedic, spinal and neurosurgical emergency/urgent cases. This is 
a reduction in theatre capacity compared to the weekday provision and in exceptional circumstances 
can lead to surgery delays, dependent on the clinical prioritisation of the caseload.  

If  emergency  admissions  are  high,  patients  are  prioritised  clinically  based  upon  their  presenting 
clinical issues. If the number of trauma admissions is particularly high, this can affect the trauma 
surgical service throughout the week and as previously advised, clinical and managerial teams work 
together to ensure emergency work is prioritised.  This can sometimes lead to the cancellation of 
planned elective work. 

The trust is also reviewing whether there is a need for a dedicated fragility fracture theatre over the 
weekend. As referenced in the response to question 2, this is a matter which is being reviewed and 
will be dependent on available clinical and financial resources.  

I do hope that the above information provides assurance that the Trust has taken the concerns raised at 
the inquest seriously. 

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. 

Yours sincerely 

CHIEF EXECUTIVE