Patricia Walton

Mrs D Hocking 
Leicester and South Leicestershire Coroner’s Court 
Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

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

23rd February 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Patricia Ann Walton who 
died on 9 January 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  5 
December 2023 concerning the death of Patricia Ann Walton on 9 January 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Patricia’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Patricia’s 
care have been listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Patricia’s family or friends. I realise that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

In your Report you raised the concern that there was insufficient medical staff cover 
over the New Year Bank Holiday period while Patrica required care. You raised that 
while  there  might  be  a  doctor  available  on  call  to  treat  emergencies,  there  is  not 
suitable cover to assess the subtleties of care required by patients who do not require 
emergency care.  

In 2016, 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, whichever day they attend at hospital. 

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 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.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 Workforce and staffing levels continue to be a challenge across the NHS and we know 
that this can present issues to Trusts. In June 2023, NHS England 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.   

NHS England has engaged with University Hospitals of Leicester NHS Trust (UHL) on 
the  matters  of  concern  raised  in  your  Report  and  has  also  been  sighted  on  their 
response to the coroner. We note that they advise that they have already increased 
medical  staffing  at  Leicester  Royal  Infirmary  and  that  during  bank  holiday  and 
weekends periods they are rostering for a medical consultant to be present 9am to 
5pm onsite, a medical registrar onsite 24hr/7days a week and by a junior doctor onsite 
24hrs/7days a week. We also note their escalation policies for staff concerned about 
deteriorating patients and that they plan to deliver an anticoagulation review service 
going forward.  

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

Chief Executive Office 
Level 3 Balmoral  
Leicester Royal Infirmary 
Infirmary Square | Leicester | LE1 5WW 

20th February 2024 

Re: Regulation 28: Report to prevent future deaths – After inquest action for 
WALTON P 

Dear His Majesty’s Coroner office for Leicester City and South Leicestershire: 

We would like to acknowledge the concerns raised in the Regulation 28 report, and 
once  again  offer  our  apologies  for  the  error  in  the  management  of  dual 
anticoagulation which led to haemorrhage for Patricia.  

We  have  put  in  place  robust  measures  to  prevent  a  similar  error  in  the  future, 
including: 

•  Changes to the way anticoagulation is prescribed in our electronic prescription 

system. 

•  Recruiting  new  staff  to  deliver  a  robust  specialist  trust  wide  anticoagulation 

review service during core working hours.  

•  Anticoagulation  is  one  of  our  key  learning  points  for  the  new  NHS  Patient 

Safety Incident Response Framework (PSRIF) starting in April 2024.  

In relation to the preventing future deaths action regarding medical staffing. We have 
already  increased  medical  staffing  at  the  site  where  the  incident  occurred.  During 
bank holiday and weekend periods, we are rostering for a medical consultant to be 
present 9am to 5pm onsite, the consultant is supported by a medical registrar onsite 
24hr/7days a week and by a junior doctor onsite 24hrs/7days a week. 

Across  all  our  sites,  patient  safety  is  the  paramount  focus  for  all  staff.  We  employ 
several  escalation  policies  for  any  staff  member  to  raise  concerns  regarding  any 
patient at any time, including: 

•  Early deterioration in physiological parameters (Early Warning Scores).  
•  A  clear  handover  process  for  nursing  teams  when  patients  are  transferred 

between wards. 
•  An  experienced 

trust  wide  deterioration  patient 

team  who  responds 

proactively to help support clinical teams.  

Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this 
did  not  impact  on  her  care.  Irrespective  of  the  time  of  year,  based  on  the  clinical 
deterioration triggers there was no cause to raise clinical concerns sooner during her 
admission. If Patricia’s clinical condition had worsened earlier, our escalation policies 
University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal 
Infirmary. 
Website:  www.leicestershospitals.nhs.uk  

 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 would  have  ensured  a  clinical  review  took  place,  regardless  of  the  bank  holiday 
weekend staffing levels.  

To strengthen our deterioration response, as of the first week in February 2024, the 
board  has  approved,  through  the  deteriorating  patient  team,  patients  and  relatives 
will be able to request an independent clinical review of care if they have unresolved 
concerns  about  potential  deterioration.  We  are  also  working  towards  making  it 
clearer and easier for patients and families to formally make their concerns known to 
clinical  staff 
ideas,  concerns,  and 
expectations.  

through  better  documentation  of 

their 

We have reviewed the potential for increasing our medical workforce across all our 
sites during bank holidays and weekends. However, as is the case for all other NHS 
trusts,  there  are  considerable  workforce  challenges  that  limit  us  in  our  ability  to 
maintain a  consistent number of  inpatient medical  staff  7 days  a week, 365  days  a 
year.  These  challenges  become  particularly  acute  during  public  holidays  when  our 
staffing  levels  reflect  the  social  cultural  context  of  UK  society  taking  holidays, 
especially during the winter holiday period.  

Time  shifting  our  medical  workforce  to  allow  a  more  even  distribution  between 
normal  days  and  weekend/bank  holidays  would  bring  significant  disruption  to  our 
existing  elective  services  including  needing  to  cancel  elective  operations  and 
outpatient  resources,  meaning  more  patients  are  placed  on  our  waiting  lists. 
However,  despite  these  challenges  over  the  Christmas  and  New  Year  period 
between  the  23rd  of  December  2023  to  1st  of  January  2024  we  had  at  least  350 
medical staff rostered to provide inpatient care across our hospitals.  

We  continue  to  develop  innovative  ways  to  improve  patient  safety  within  our 
allocated  resources  and  will  work  with  the  national  team  to  explore  all  options  to 
address workforce challenges.  

Yours sincerely 

Chief Executive 
University Hospitals of Leicester NHS Trust and University Hospitals of Northamptonshire 
NHS Group 

2