Tamara Davis

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

10 December 2024 

Our ref: 

HM Coroner Andrews 
Records Office,  
Orchard Street,  
Chichester,  
West Sussex 

By email: 

Dear Ms Andrews, 

Thank you for the Regulation 28 report of 24 October 2024 sent to the Department of Health 
and Social Care about the death of Ms Davis. I am replying as the Minister with responsibility 
for urgent and emergency care.      

Firstly, I would like to say how saddened I was to read of the circumstances of  Ms Davis’ 
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, my officials have made enquiries with NHS England  to ensure 
your concerns are adequately addressed. 

The report raises concerns over emergency department capacity, poor patient flow and the 
use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand 
that your report and matters of concerns have also been sent to NHS England, and they are 
best placed to respond with the specific actions being taken locally to improve urgent and 
emergency care performance at RSCH.   

At a national level, this government is committed to returning to the safe operational waiting 
time  standards  set out  in  the  NHS  Constitution. In doing  so,  we  will  be  honest  about  the 
challenges facing the health service and serious about tackling them. The Health Secretary 
ordered an independent investigation of NHS performance to provide an assessment of the 
issues and challenges it faces. This report was published on 12 September 2024 and the 
investigation’s findings are feeding into the government’s work to develop a 10-year plan to 
radically reform the NHS and build a health service that is fit for the future.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 
 The plan's reforms will support a reduction in the demand pressures on the health service 
through three shifts to ensure the health service can tackle the problems of today and 
tomorrow. These are: 

•  shifting care from hospitals to the community,   
• 
•  sickness to prevention.  

from analogue to digital, and 

In  the  short-term,  the  NHS  is  taking  a  range  of  action  this  year  to  improve  urgent  and 
emergency  care  performance,  including  maintaining  increases  in  acute  hospital  bed 
capacity and greater ambulance hours on the road. There is also a focus on increasing the 
productivity of acute and non-acute services across bedded and non-bedded capacity and 
directing  patients  to  more  appropriate  services  in  the  community  where  these  can  better 
meet their needs.   

I share your concerns regarding the use of Temporary Escalation Spaces (TES), also known 
as  corridor  care,  at  RSCH.  NHS  England  highlighted  key  expectations  regarding  patient 
safety  and  overcrowding  management  in  emergency  departments  in  its  winter  operating 
assumptions  letter,  published  on  16  September  2024:  https://www.england.nhs.uk/long-
read/winter-and-h2-priorities/. The letter reminds Integrated Care Boards and provider Chief 
Executives to prioritise patient safety and experience. 

The  guidance  urges  NHS  trusts  to  ensure  that  care  outside  standard  cubicles  or  ward 
environments is not normalised and is employed only during periods of elevated pressure. 
Furthermore, TES use should be escalated to an appropriate executive member and at the 
system level, with the aim of minimising its duration. These recommendations align with the 
recently issued guidance on TES, which can be found via https://www.england.nhs.uk/long-
read/principles-for-providing-safe-and-good-quality-care-in-temporary-escalation-spaces/ 

I agree with your concerns that the delivery of care in TES is not acceptable and should not 
be  considered  as  standard  practice.  All  patients  should  be  able  to  access  the  highest 
possible levels of patient experience, care and safety during their treatment. I understand 
that NHS England will address what RSCH is doing to mitigate use of TES in their reply to 
you. 

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

Yours sincerely,  

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 MINISTER OF STATE FOR HEALTH

Joanne Andrews 
Area Coroner 
The Coroner’s Office,  
Woodvale,  
Lewes Road,  
Brighton  
BN2 3QB 

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

24 December 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Tamara Davis who died 
on 13 December 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  15 
October  2024  concerning  the  death  of  Tamara  Davis  on  13  December  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Tamara’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Tamara’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to respond to your Report, and I 
apologise for any anguish this delay may have caused to Tamara’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.  

Your  Report  raises  the  concern  that  patients  are  being  treated  in  the  corridors  of 
Emergency Departments when the departments have reached their full capacity and 
space  in  clinical  areas  is  not  available.  This  is  considered  by  the  Coroner  to  be  a 
national  issue  and  does  not  just  apply  to  the  Royal  Sussex  County  Hospital in 
Brighton, where Tamara passed away. 

My  response  to  the  Coroner  has  been  informed  by  colleagues  in  the  Urgent  and 
Emergency Care Team at NHS England and the South East Regional Clinical Quality 
Improvement Team. 

The  delivery  of  care  in  temporary  escalation  spaces  (TES)  in  departments 
experiencing  patient  crowding  (including  beds  and  chairs)  is  not  acceptable  and 
should not be considered as standard across the NHS. TES refers to care given in any 
unplanned settings (such as corridors) and recently NHS England have published a 
set of principles for supporting improved quality of care should patient demand outstrip 
capacity  -  NHS  England  »  Principles  for  providing  safe  and  good  quality  care  in 
temporary  escalation  spaces  (16  September  2024).  These  principles  have  been 
developed  to  support  point-of-care  staff  to  provide  the  safest,  most  effective  and 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
  
 
  
 highest quality care possible when TES care has been deemed necessary, and the 
principles should be applied alongside any local standard operating procedures and 
arrangements governing flow pathways and safe staffing.  

In the meantime, NHS England is working through the operating model so that NHS 
England’s  Regions  can  support  providers  to  eliminate  crowding  in  Emergency 
Departments in the longer term.  Improvements are being demonstrated through NHS 
England’s  operational  planning  guidance,  where  systems  were  asked  to  focus  on 
areas to deliver improved patient flow, and this has included increasing the productivity 
of acute and non-acute hospital services, improving flow and length of stay, as well as 
clinical outcomes. In addition to this, we are continuing to develop services that shift 
activity from acute hospital settings to settings outside an acute hospital for patients 
with unplanned urgent needs, supporting proactive care, alternatives to admission and 
improving hospital discharge.  

My  Regional  colleagues  in  the  South  East Clinical  Quality  Improvement  team  have 
recently  visited  the  Emergency  Departments  at both  University  Hospitals Sussex  in 
Worthing and Royal Sussex County Hospital as part of a programme of joint Nursing 
and Integrated Care Board (ICB) visits to NHS Trusts, led by their Deputy Director. 
The  programme  of  visits  aims  to  understand  how  and  why  patients  are  selected  to 
reside  in  non-designated  areas,  how  they  are  observed  for  deterioration,  and  how 
dignified  care  can  be  provided.  These  focused  reviews  of  non-designated  care 
practices in the Emergency Department have included engaging with staff, patients 
and relatives to test safety measures in place and provide detailed feedback for the 
organisations on areas for improvement.  

NHS England has also reviewed the response to the Coroner from University Hospitals 
Sussex NHS Foundation Trust dated 10 December 2024. We note and welcome the 
various  workstreams  in  place  to  improve  flow  through  the  hospital,  reduce  hospital 
attendance and optimise discharge pathways.  

I  would  also  like  to  provide  further  assurances  on  the  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  events,  such  as  the  sad  death  of 
Tamara, are shared across the NHS at both a national and regional level and helps 
us to 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

HM Area Coroner  
Ms Joanne Andrews 
West Sussex, Brighton and Hove 
Parkside Chart Way 
Horsham 
RH12 1XH 

10 December 2024 

Dear Ms Andrews 

University Hospitals Sussex NHS Foundation Trust 
Trust Headquarters 
Royal Sussex County Hospital 
Eastern Road 
Brighton 
BN2 5BE 
www.uhsussex.nhs.uk   

Your ref: 

Our ref: 

Inquest into the death of Tamara Davis  

Thank  you  for  your  letter  of  15  October  2024,  enclosing  your  formal  report  under 
Regulation  28  to  Prevent  Future  Deaths,  to  NHS  England  &  NHS  Improvement, 
Department of Health and Social Care, and the Trust. 

First, my sincere condolences to Tamara’s family. 

Thank  you  for  confirming  that  the  period  in  which  Tamara  was  in  the  Emergency 
Department  (ED)  corridor  did  not  cause  or  contribute  to  Tamara’s  death.  However,  I 
understand that you are concerned that caring for patients in the ED corridor may create a 
risk of future deaths. 

Your Regulation 28 report has been reviewed by both the Executive team and the Medicine 
Division, including the Chief of Service and the Divisional Director of Nursing.  

As  you  know  from  the  inquest,  the  Medicine  Divisional  Leadership  team  are  working 
alongside  the  Hospital  Directors  and  Executive  team  on  several  separate  but  linked 
workstreams,  all  with  the  overarching  aim  to  eradicate  the  use  of  the  ED  corridor  for 
patients.   

The  Medicine  Divisional  Improvement  Board  has  been  developed  to  oversee  and 
implement  a  number  of  improvement  actions  to  enable  this  to  be  achieved.  The  focus  is 
also  to  improve  the  safety,  quality  of  care,  and  overall  outcomes  and  experience  for 
patients presenting to the ED. 

The Medicine Division have employed an Operational Flow Improvement Manager  who is 
leading  the  Hospital  Alternative  Oversight  Programme.  The  aim  of  this  work  is  to  reduce 
admissions,  optimise  flow  through  the  hospital,  and  smooth  discharge  pathways  and 
processes. A number of the initiatives already in progress are as follows:  

•  Unscheduled Care Navigation Hub 
•  Frailty Care Home Outreach & Red Bag Launch 
•  Frailty High-Weald Lewes & Havens Outreach 
• 

Integrated Front Door Therapies Team RSCH (Royal Sussex County Hospital) 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 Interprofessional Standards  

•  Virtual Health, both General Virtual Ward and Respiratory Home Monitoring Services  
•  Frailty & Respiratory SDEC (Same Day Emergency Care) Optimisation 
• 
•  UTC (Urgent Treatment Centre) Optimisation  
•  Early Discharge Planning  
•  Deconditioning Prevention 
•  Tiered Acuity Model 

These initiatives are in collaboration with colleagues from the ICB (Integrated Care Board), 
Sussex Community NHS Foundation Trust (SCFT), South East Coast Ambulance Service 
(SECAmb) and Brighton & Hove City Council (BHCC). 

Unscheduled Care Navigation Hub 

In the Southeast, only 2.1% of call outs are conveyed somewhere other than ED. There is 
underutilisation of alternative pathways to admission, with 53.9% of incidents conveyed to 
ED.  This  model  seeks  to  enhance  the  hear  &  treat  and  see  &  treat  performance  of 
SECAmb and reduce attendance to our hospitals where appropriate, and act as pre-cursor 
to NHS England’s Single Point of Access (SPOA) model. 

Continuous Flow Model - Reducing overcrowding in the Emergency Department 

Continuous Flow will improve the early movement of patients from the Acute Floor. This will 
improve the quality of care for patients who are being treated in non-clinical spaces in the 
ED.  In  addition,  it  will  reduce  the  time  patients  are  waiting  in  the  ED,  in  particular  it  will 
reduce patients waiting over 12 hours for admission to a ward. 

The continuous flow model commenced on 11 June 2024 and provides guaranteed transfer 
of  patients  from  the  Acute  Assessment  Unit  (AAU)  to  the  Specialty  Medicine  and  Frailty 
wards  at  set  times  planned  in  advance.  This  is  currently  being  implemented  across  the 
Trust.  

Surgical Assessment Unit (SAU) 

The SAU opened in October 2024 and is being expanded in line with nursing recruitment. 
This will increase the hospital’s bed stock by 12 patient trolley beds and 12 patient chairs. It 
is  expected  to  manage  most  surgical  patient  presentations  to  the  ED  and  receive 
ambulances directly.  

The  SAU  represents  the  first  phase  of  our  Acute  Floor  Reconfiguration  which  is  a  £48 
million capital improvement programme that will improve patient and staff experience at the 
RSCH significantly. 

I hope this letter provides you and Tamara’s family with assurance that we are committed 
to  making  significant  improvements  to  patient  flow  and  the  quality  and  safety  in  the 
Emergency Department. Once again, my sincere condolences to Tamara’s family.  

Yours sincerely 

Chief Executive