Tracey Farndon

From Maria Caulfield MP 
Parliamentary Under-Secretary of State for  
Mental Health and Women's Health Strategy 
Department of Health and Social Care 

39 Victoria Street  
London  
SW1H 0EU  

Louise Hunt  
HM Senior Coroner for Birmingham and Solihull,  
The Birmingham and Solihull Coroner’s Court,   
Steelhouse Lane,   
Birmingham,  
B4 6BJ 

13 May 2024  

Dear Mrs Louise Hunt,  

Thank you for your Regulation 28 report to prevent future deaths dated 05/04/2024 on the 
death of Tracey Ann Farndon. I am replying as Parliamentary Under Secretary of State 
(Minister for Mental Health and Women’s Health Strategy).   

I was saddened to read of the circumstances of Tracey’s 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.   

Your report raises concerns over a failure to identify and treat sepsis within the emergency 
department at Queen Elizabeth Hospital in Birmingham, and highlights the following matters 
of concern:   

1.  The Emergency Department (ED) was, and continues to be, overwhelmed with patients 
with insufficient staff to care for, monitor and manage those patients. There is also 
continued regular use of agency staff.   

2.  Staff failed to consider a diagnosis of sepsis throughout Ms Farndon’s admission. This 

raises the concern that staff do not fully understand the variable signs and symptoms of 
sepsis.   

3.  Ms Farndon’s blood pressure (BP) was not recordable when she first presented at the 

emergency department. It was likely to be very low. This was not considered by the staff 
and no further attempts were made to assess Ms Farndon’s BP. This raises concern that 
staff do not understand the implication of a low BP, the importance of continued 
observations when a key parameter cannot be recorded and that this may indicate the 
patient is seriously unwell.  

  
  
  
  
  
  
  
  
   
 
                                                                                             
   
  
  
  
 In preparing this response, DHSC officials have made enquiries with NHS England. NHS 
England also consulted with University Hospitals Birmingham NHS Trust on local actions 
taken. The following response addresses each of your matters of concern in turn.   

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. We must 
do all we can to learn from tragic incidents such as Ms Farndon’s death to ensure the safety 
of health services and prevent future deaths.   

Your report raised concerns about the demand and capacity in Queen Elizabeth Hospital’s 
Emergency Department. I recognise the significant pressure the urgent and emergency care 
system is facing. That is why we published our ‘Delivery plan for recovering urgent and 
emergency care services’, which aims to deliver sustained improvements in waiting times. 
Our ambitions include improving the Accident and Emergency (A&E) Department waiting 
times and reduce overcrowding, so that, by March 2025, 78% of patients are admitted, 
transferred, or discharged from A&E within four hours. A&E waiting times have improved this 
year following the delivery plan’s publication, with national A&E 4-hour performance 
improving from 71.5% in March 2023 to 74.2% in March 2024.  

A key part of the plan has been to increase hospital capacity to reduce overcrowding in A&E. 
We have delivered 5,000 more staffed, permanent beds this year compared to 2022-23. A 
whole-system approach is needed to ensure people get the emergency care they need. This 
is why £1.6 billion of funding has been made available over two years to support the NHS 
and local authorities to ensure timely and effective discharge from hospital, helping to free up 
beds and reduce long waits for admission from A&E.   

The commitment to improving patient safety is highlighted in the first NHS Patient Safety 
Strategy. This spring, NHS England will launch a deterioration toolkit called ‘PIER’ which 
stands for Prevention, Identification, Escalation and Response. This suite of resources will 
be accompanied by improvement support delivered by Patient Safety Collaboratives and 
targeted at Integrated Care Systems to improve deterioration pathways. This programme of 
work will also incorporate the implementation of ‘Martha’s Rule’, which will be rolled out to at 
least 100 acute NHS trusts in 2024-25. ‘Martha’s Rule’ will allow inpatients and families to 
request a rapid review 24 hours a day when a patient’s physiological condition is thought to 
be deteriorating.  

We aim for all acute trusts in England to use PIER to create and implement deterioration 
improvement plans, alongside Matha’s Rule. This will help staff to ensure an individual’s vital 
sign baseline (including blood pressure) is understood and that a range of risk assessment 
tools and methods are used to identify, monitor and mitigate their risk of deterioration.   

We must ensure clinicians, and other NHS staff, can recognise unwell and deteriorating 
patients. The National Early Warning Score (NEWS2) is a system for scoring the 
physiological measurements that are routinely recorded at the patient's bedside to support 
clinicians in identifying acutely unwell patients, including those with suspected sepsis. Since  
2018, NEWS2 has been implemented across 98.4% of acute trusts and 100% of ambulance 
trusts in England.   

Despite the widespread use of NEWS2, some patients who deteriorate with sepsis are still 
not diagnosed quickly enough. To address that, ‘Recording of NEWS2 score, escalation and 
response time for unplanned critical care admissions’ was identified as a clinical priority area 
for the NHS over 2023/2024. It was included in the Commissioning for Quality and 
Innovation (CQUIN) scheme in 2023/2024, which aimed to incentivise the use of NEWS2 to 
improve care by ensuring appropriate steps are taken to record and respond to deterioration.   

Sepsis requires early recognition and prompt treatment with antibiotics. In May 2022, the 
Academy of Medical Royal Colleges published a position statement on the initial 
antimicrobial treatment of sepsis. Subsequently, in March 2024, the National Institute for 
Health and Care Excellence (NICE) updated Guideline 51 on suspected sepsis. It is critical 

 
 
 
 that updates to national sepsis guidance are disseminated and well recognised amongst a 
wide range of healthcare professionals who may encounter sepsis and acute deterioration. 
NHS England has developed several sepsis training and education resources, including e-
learning, sector specific toolkits, and the ‘sepsis educational digital game,’ an accessible 
introduction to sepsis for clinical and non-clinical staff. We will continue to work with NHS 
England to understand what resources are needed ensure that healthcare professionals 
recognise and respond appropriately when patients deteriorate.   

Furthermore, there is a commitment to drive evidence generation in this area. In 2022, the  
National Institute for Health and Care Research (NIHR) awarded £3.2m of funding to the 
Sepsis Trials In Critical Care study (SepTIC), which will look to answer critical questions on 
sepsis diagnostics and treatment. NIHR continues to fund many ongoing studies into sepsis 
and welcomes applications for further research in this area.  

Your report also raised concerns regarding the assessment of Ms Farndon’s low blood 
pressure. I note you have shared your report and concerns with University Hospitals 
Birmingham NHS Foundation Trust, to respond directly to your matters of concern. I have 
included below some of the local actions that the Trust has committed to in response to the 
concerns in your report.   

Firstly, the trust has acknowledged the need for further clinical skills training for nursing staff, 
which includes being competent and confident in taking manual blood pressure readings. 
Queen Elizabeth Hospital’s A&E department has also recognised that an alternative method 
of assessing perfusion, such as checking the radial pulse, is needed in addition to manual 
blood pressure. The Trust have agreed to include this in its induction programme along with 
an educational update to increase awareness and compliance. The A&E standard operating 
procedure will be updated to reflect that any observations that are incompletely documented 
must be handed over to the patient's nurse, with the need to repeat the observations being 
clearly documented.   

In addition, feedback has been given to all staff involved in Ms Farndon’s care. The Trust has 
recognised that further education is required by clinical staff to be able to identify patients 
with possible sepsis having back pain, gastrointestinal symptoms and/or being afebrile. This 
learning will be shared at Morbidity and Mortality meetings, through local training and via the 
ED Safety Newsletter. The Trust has also acknowledged the need for a review of both the 
“Role & Responsibility Action Cards” for staff leads on shift, and the escalation procedures 
within ED.  

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

Best Wishes,   

MARIA CAULFIELD

Executive Office of the Chair & Chief Executive 

28th May 2024  

Mrs Louise Hunt  
HM Senior Coroner for Birmingham and Solihull  

Dear Mrs Hunt  

Inquest touching the death of Tracey Ann Farndon 
Response to Regulation 28 Report to prevent future deaths 

I  am  writing  in response  to the  Regulation 28  notice issued following  the  conclusion  of the 
inquest on 5th April 2024, into the sad death of Tracey Ann Farndon on April 25th, 2023, at 
Queen  Elizabeth  Hospital  Birmingham  (part  of  University  Hospitals  Birmingham  NHS 
Foundation Trust (UHB)).  I extend my sincere condolences to Mrs Farndon’s family.  

I note your narrative conclusion as “Natural causes contributed to by a delay in diagnosis and 
treatment of sepsis. Her death was contributed to by neglect.”  I further note your concerns 
regarding risks of future deaths, which have been addressed in turn below.  The focus of the 
actions  has  been  at  the  Queen  Elizabeth  Hospital  Birmingham  (QEHB),  but  the  learning 
identified  in  this  response  has  been  shared  with  each  of  the  responsible  Hospital  Medical 
Directors  and  Directors  of  Nursing  covering  QEHB,  Heartlands  Hospital  and  Good  Hope 
Hospital, respectively, for implementation. 

 Concern 1: 

The inquest heard how the Emergency Department at QEHB was, and continues to be, 
overwhelmed with patients with insufficient staff to care for, monitor and manage those 
patients. There is continued regular use of agency staff. This directly impacts patients' 
safety and is a risk of future deaths.  

It  is  recognised  that  Emergency  Department  (ED)  crowding,  where  the  demands  on  the 
department exceed the capacity, can have a negative impact on patient outcomes and staff 
(Royal  College  of  Emergency  Medicine:  The  Management  of  Emergency  Department 
Crowding,  January  2024).  Solutions  require  whole  systems  interventions.  Causes  and 
interventions to minimise the risk of crowding can be considered in terms of: 

1)  Output – The inability of patients to leave the ED once their care is completed. 

UHB has Trust wide Standard Operation Procedures for Trust Capacity Escalation, and 
for  circumstances  where  the  Emergency  Departments  reach  full  capacity.  These  are 
followed in conjunction with the operational policy for managing ambulance offload delays. 
At each site, there are bed meetings held throughout the day to identify beds for patients 
requiring admission to ward areas. A member of the site team is present in each of the 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
       
  
  
 
 
 
 
 
 
 
 UHB Emergency Departments between the formal bed meetings to liaise with the nurse in 
charge and Consultant and ensure patients are transferred to the allocated beds as soon 
as  they  become  available.    There  are  dedicated  escalation  processes  in  place  with 
Birmingham  and  Solihull  Mental  Health  Foundation  Trust  and  Birmingham  and  Solihull 
Integrated  Care  Board  to  ensure  that  patients  with  mental  health  issues  requiring 
admission are transferred from the ED as soon as possible.   

At QEHB, for patients awaiting medical review who are likely to be able to be discharged 
following appropriate investigation and management, we have increased the number of 
patients  referred  to  the  acute  medicine  Same  Day  Emergency  Care  (SDEC)  area,  and 
created  a  frailty  SDEC  in  November  2023,  where  frailer  patients  can  receive  the 
appropriate medical and therapy input. Through reconfiguration of the QEHB ED, we have 
reintroduced  an  Emergency  Observation  Unit  (EOU)  for  patients  that  do  not  require 
admission but may require additional monitoring or investigation prior to discharge from 
the ED. The QEHB EOU was opened March 2024.  

2)  Throughput – processes within the ED 

a)  ED staffing 

i.  Nursing 

A staffing matrix is used as a forward look to ensure sufficient staffing for each level of 
seniority  on  every  shift,  with  an  escalation  process  for  predicted  shortfalls.  ED  staff 
utilise  shift  logs  and  quality  and  safety  checklists  to  ensure  patients  receive  the 
appropriate care, monitoring, and management. 

There has been an improvement in nursing recruitment, with a significant reduction in 
the use of agency staff in ED at QEHB. In May 2023, over 600 shifts per month were 
filled with external registered staff. This has reduced to 164 shifts in April 2024, with a 
projection to withdraw external agency requests at the end of June 2024.  

ii.  Medical 

Due to under-recruitment, medical middle grade rosters (Specialist Registrar level or 
equivalent)  in  QEHB  ED  remain reliant  on  locum  staff,  but  the majority  of  shifts  are 
filled by doctors who work regular shifts in the department and are therefore familiar 
with hospital processes.  

Since May 2023, at QEHB there has been an additional dedicated Consultant in the 
ED Ambulatory Area (EDAA) until midnight, with the aim of improving flow.  

b)  Reconfiguration of the department 

We  have recognised that the  current  layout  of the ED  at QEHB  causes significant 
challenges  to  operational  performance.  The  EDAA  area  was  initially  created  to 
mitigate the physical distancing demands of the Covid pandemic, but its layout and 
location away from the main department poses risks to patients clinically and staff 
logistically. We will therefore be reducing the size of the EDAA to treat minor injuries 
and referrals to the on-site urgent care GP led service only. This will occur from June 
2024, and will allow us to focus staff to provide care within the main ED footprint. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 c)  Rapid Assessment and Triage and eTriage 

In  conjunction  with  the  physical  reconfiguration  of  the  department,  we  will  be 
introducing eTriage to help identify the high acuity patients earlier on in their arrival 
before the full triage, and to help prioritise sicker patients in a busy ED. This system 
utilises the Manchester Triage System and is expected to be implemented at QEHB 
ED  in  June  2024.  Introduction  of  eTriage  will  follow  at  our  other  Emergency 
Departments as soon as possible. 

A  Rapid  Assessment  and  Triage  (RAT)  process  is  being  re-established  for 
ambulance and walk in patients. This will ensure that all patients will be reviewed by 
a  senior  decision  maker  and  senior  nurse  soon  after  arrival,  with  an  initial 
investigation and management plan instigated. RAT will be in place at QEHB by early 
June 2024, and will increase the safety of walk-in patients and patients in the waiting 
room.  The effectiveness of current assessment and triage pathways at Heartlands 
and  Good  Hope  Hospitals  is  also  under  review  and  the  feasibility  and  utility  of 
introducing RAT in these EDs is being considered.   

3)  Input – influences before the patient arrives at the ED 

We have worked with system partners to introduce measures to try and reduce the number 
of patients presenting to each of our EDs.  

At QEHB, this includes: 

a)  Reintroducing direct GP referrals to the Same Day Emergency Care area run by Acute 
Medicine – this was implemented in January 2024, and has seen a marked increase 
in the number of GP referrals to SDEC.  

b)  In  December  2023,  a  “Call  before  you  convey”  process  was  introduced  across  the 
West  Midlands  region.  This  facilitates  ambulance  clinicians  to  access  acute  and 
community  teams  for  a joint  clinical  discussion to  support  the right  care for  patients 
aged over 60 years.  

c)  UHB works closely with West Midlands Ambulance Service and the ED has an agreed 

Standard Operating Procedure for managing Ambulance Offloads.   

Concern 2: 

The  inquest  heard  how  staff  failed  to  consider  a  diagnosis  of  sepsis  throughout  Ms 
Farndon's admission. There is a concern that staff do not fully understand the variable 
signs and symptoms of sepsis and there is a risk of future deaths.  

There  is  a  dedicated  Trust  Sepsis  Group  which  proactively  audits  compliance  with  sepsis 
pathways across the organization. The emergency department at QEHB routinely identifies 
and successfully manages a large number of patients with sepsis. Between January and April 
2024,  the  department  identified  900  patients  with  sepsis,  847  (94%)  of  whom  received 
antibiotics intravenously within an hour of their diagnosis.  

 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  response  to  events  surrounding  Ms  Farndon’s  death,  the  ED  department  at  QEHB  has 
initiated a programme of sepsis training. This includes: 

Identifying sepsis champions at all grades of staff 

• 
•  Utilising Trust and Sepsis UK resources for educational events, with focussed sepsis 
events  planned  for  May  and  June  2024.  Pre  and  post  education  assessments  will 
evaluate whether training improves knowledge. 

•  Displaying sepsis specific information on safety boards  

A rolling audit programme of completion of the Sepsis 6 Bundle has been established, and 
sepsis  training  is  included  in  the  induction  programme  for  all  new  staff  and  in  regular 
educational training updates. Sepsis is part of the educational and training programmes for all 
junior medical staff.   

The Trust utilises sepsis screening using NEWS2, which is automatically calculated from the 
physiological  observations  recorded  in  the  electronic  medical  records’  system.  Alerts  to 
consider sepsis are generated automatically when the NEWS2 is equal to or greater than 5. 
However, a significant focus of training is “call for concern” where a patient may have sepsis, 
but the NEWS2 score is less than 5.  

Sepsis  screening  will  be  embedded  in the  Rapid Assessment  and Triage process,  and the 
early involvement of senior clinicians in the review process for walk in and ambulance patients 
will facilitate recognition of sepsis across the spectrum of presentation.  

Concern 3: 

Ms  Farndon’s  BP  was  not  recordable  when  she  first  presented  at  the  emergency 
department. It was likely to have been be very low. This was not considered by the staff 
concerned and no further attempts were made to assess Ms Farndon’s BP. There is a 
concern  staff  do  not  understand  the  implication  of  a  low  BP,  the  importance  of 
continued observations when a key parameter cannot be recorded and that this may 
indicate the patient is seriously unwell. This raises a concern of future deaths.  

A  programme  of  manual  blood  pressure  training  and  competence  was  commenced  for  all 
Emergency Department staff at QEHB in March 2024. This includes education regarding the 
limitations  of  electronic  blood  pressure  measurement,  for  example  the  unreliability  when 
patients have atrial fibrillation, and the escalation process for situations when blood pressure 
cannot  be  recorded.  All  band  6  and  band  7  staff  who  are  not  on  extended  leave  have 
completed this training, with all band 5 staff expected to have completed training by the end 
of May 2024. There is always a dedicated senior emergency doctor in all areas to escalate to 
for urgent review if the blood pressure is unable to be recorded through automatic or manual 
means. Training also includes education regarding additional means of assessing perfusion 
such  as  palpation  of  radial  pulse  and  capillary  refill  time.  The  Trust  Clinical  Guidelines  for 
taking a Non-Invasive Blood Pressure Measurement in adult patients have been disseminated 
to all staff. The Rapid Assessment and Triage process will ensure that there is a senior nurse 
and senior decision maker on initial review.  

Mindful of the relevance of this concern to UHB ward areas, a Moodle educational package 
has been created for all UHB staff which covers fundamental observations including how to 
complete a manual blood pressure. The clinical skills team will be running drop-in sessions for 
staff to refresh their knowledge in this skill.  

 
 
 
 
 
 
 
 
 
 
 I would like to assure you that the concerns raised within the Regulation 28 Report have been 
taken  extremely  seriously,  which  I  hope  is  demonstrated  in  the  steps  we  have  taken  in 
reviewing and strengthening our systems, processes and training provision to our teams. 

Yours sincerely   

Chief Executive