Jean Langan

Minister of State for Health (Secondary Care)  

39 Victoria Street  
London  
SW1H 0EU  

20 February 2025  

Our ref: 

HM Coroner Ian Michael Arrow  
The County of Devon, Plymouth and Torbay  
County Hall  
Topsham Road  
Exeter  
Devon EX2 4QD  

By email: 

Dear Mr Arrow  

Thank you for the Regulation 28 report of 13 December 2024 sent to the Secretary of State 
for Health and Social Care about the death of Ms Jean Langan. I am replying as the Minister 
of State for Health with responsibility for the NHS Estate.        

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Langan’s 
death, and I offer my sincere condolences to their 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.  

The report raises concerns over:  

•  A need for a real time data base of Hospital Helicopter Landing sites to ensure the safe 

landing of helicopters.   

•  A need to ascertain the contact details of the relevant manager of each Helicopter landing 

site at all Hospital Trusts which receive helicopters.   

•  More particularly to address the points below, as set out by Hogan Lovells who are the 
representative for the Air Service Operator Bristows in the letter of the 6 of December 
2024: 

1)  Details  of  the  responsible  person/accountable  manager  for  each  NHS  England 
hospital with a Hospital Helicopter landing site (HHLS).  
2) Copies of all Standard Operating Procedures as they exist now insofar as they relate 
to helicopter operations.   

 
 
  
  
  
   
  
  
  
  
  
  
  
  
  
  
  
 
 3) An update on the status of their Helicopter Operations Manual (HOM) with target date 
for completion.   
4) Confirmation that NHS Trusts have engaged with the Civil Aviation Authority (CAA) to 
ensure  all  relevant  personnel  have  attended  or  are  planned  to  attend  the  CAP  1264 
course. A target date for completion should be provided.   

In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS  England  and  the 
Department for Transport to ensure we adequately address your concerns.  

We  will  learn from  this tragic  event  and  will  take action  to help  mitigate  the  risk  posed  to 
members  of  the  public,  staff,  and  flight  crew  at  hospital  helicopter  landing  sites  (HHLSs) 
across the UK. DHSC has a limited role in enforcing HHLS safety.   

DHSC has carefully considered your report and its recommendation to develop a database 
of  HHLSs.  We  are  engaging  with  NHS  England  and  the  Department  of  Transport  to 
determine  how  best  to  implement  this  recommendation  and  ensure  a  database  is  fit  for 
purpose.  Turning  to  your  recommendation  to  ensure  each  HHLS  has  an  accountable 
manager, we agree a named accountable manager is essential for the safe running of HHLS 
and  NHS  England  now  have  this  information  for  all Trusts. As  of  the  31  January  2025  a 
named  accountable  manager  has  been  identified  and  supplied,  this  is  essential  to  the 
establishment and maintenance of an HHLS database.  

DHSC has worked with NHS England to implement the requests in the letter (noted above) 
from  Bristow’s,  the  Helipad  operator  for  Search  and  Rescue  Service  (SARS)  helicopters 
dated the 6th of December 2024 to the coroner. Work is currently ongoing to deliver this.   

HHLS are not licensed landing sites like aerodromes or airports. Instead, the Civil Aviation 
Authority (CAA) provides non-statutory guidance to the NHS on HHLSs, through the Civil  
Aviation Publication (CAP) 1264 “Standards for helicopter landing areas at hospitals”. This 
guidance  covers  issues  such  as  operation  and  management,  covering  approach  and 
departure paths, obstacle clearance, lighting, signage, and communication protocols.   

NHS England expects NHS trusts to follow the CAP1264 guidance. Through work they are 
undertaking to address the points set out above (and in Bristow’s letter of 6 December) NHS 
England will ensure that HHLS meet the CAP 1264 requirements, as appropriate.  

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

Yours sincerely,   

MINISTER OF STATE FOR HEALTH

From the Secretary of State 

Department for Transport 
Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Tel: 
E-Mail: 

5 February 2025 

I M Arrow 
County Hall 
Topsham Hall 
Exeter 
Devon 
EX2 4QD 

Dear Mr Arrow, 

Prevention of Future Deaths Notice 

Thank you for your report of 13 December 2024 (Case Reference 
made under the Coroners and Justice Act 2009 and the Coroner’s 
(Investigations) Regulations 2013, following the inquest conducted into the 
death of Jean Langan. 

) 

The Department for Transport (DfT) are deeply saddened by the 
circumstances of Jean Langan’s death, and we would like to extend our 
condolences to her family and friends. 

We will learn from this tragic event and are taking action to mitigate the risk 
posed to members of the public, staff and flight crew at hospital helicopter 
landing sites (HHLSs) across the UK. Since 2020, there have been three 
downdraft events in the UK (excluding the Derriford Incident) investigated by 
the Air Accident Investigation Branch (AAIB). These all involved air 
ambulances operating on scene away from HHLSs, with two resulting in 
injuries to members of the public. The DfT is aware of the risks posed by 
rotary aircraft and will continue to endeavour to mitigate these as far as 
possible. 

Hospitals are responsible for the safety of HHLSs located on their grounds. 
The DfT is responsible for overseeing the safety only of licenced helipads. 
Currently, all HHLSs are unlicenced. This means they do not have to comply 
with CAA’s CAP 1264 guidance for hospital helicopter landing areas. 

 
 However, we are determined to play our part in reducing the risk at these 
sites as far as possible. We are also acting on the AAIB’s recommendation 
to strengthen oversight of HHLSs. In conjunction with the CAA and industry, 
the DfT is currently considering whether to legislate to ensure safety at all 
HHLSs. This would be a long-term (2-4 year) project requiring secondary 
legislation.  

The DfT has carefully considered your report and its recommendation to 
develop a database of HHLSs. It is the responsibility of hospitals to procure 
and maintain any database. We will assist DHSC, hospitals and the NHS by 
developing options for a database that meet your and the AAIB’s 
recommendations. We have already started this work. DfT is the co-chair of 
the Onshore Leadership Group (OnSLG), a forum of rotary operators 
including air ambulances, Bristow Helicopters and utility operators. This has 
helped us to investigate how a dynamic and comprehensive database of all 
HHLSs can be established. We have also spoken to the supplier of the 
offshore helipad database, and the existing supplier of mapping software to 
much of the air ambulance and SAR communities. The DfT also participates 
in several other industry-wide forums such as the NHS HHLS Group, the 
New Hospital Programme HHLS Forum and the Air Ambulance Operation 
Director’s Group.  

We understand that the Department of Health and Social Care (DHSC) will 
respond on your recommendation to ensure each HHLS has an accountable 
manager. We also understand that DHSC will work with NHS England to 
implement the demands in Bristow’s letter of 6th of December 2024. A 
named accountable manager is essential to the establishment and 
maintenance of an HHLS database, and the DHSC is working with national 
health authorities to ensure that each HHLS has a named and competent 
accountable manager.  

Yours sincerely, 

SECRETARY OF STATE FOR TRANSPORT

Trust Headquarters 
Health and Wellbeing Centre 
Sandwell General Hospital 
Lyndon 
West Bromwich 
B71 4HJ 

Mr Z Siddique 
HM Senior Coroner  
Black Country Coroner’s Court 
Jack Judge House 
Halesowen Street 
Oldbury B69 2AJ 

12th December 2025  

Re: Mrs Sultana (deceased) 

Dear Mr Siddique,  

Thank you for your Prevention of Future Deaths report of 23 October 2025 raising the concerns 
you  have regarding following  two points  within  the Sandwell and West Birmingham NHS Trust 
policies:  

  There was confusion and lack of understanding by nursing staff in relation to when the 

EMRT should be called in an emergency particularly when a DNAR was place.  

  There was a lack of risk assessment of when SALT assessments for those patients at risk 

of dysphagia should take place.  

We have taken appropriate steps to address your concerns and ensure that staff have the clarity 
required  to  support  decision  making  when  required  in  the  emergency  situation.    We  have 
undertaken the actions listed below: 

  Amended the Emergency Medical Response Team (EMRT) policy to clarify that EMRT calls 
are  appropriate  when  there  is  an  immediate/recoverable/un-expected  event  such  as 
choking  or  airway  compromise  –  even  when  a  Do  Not  Attempt  Cardiopulmonary 
Resuscitation (DNACPR) is in place 

  This policy has been uploaded onto the policies platform to ensure availability to all staff 

who require it – staff will be notified of a new version being available 

  The policy update has been communicated to Senior Leaders, Governance and Safety 
leads  and  team  leader/ward  management  within  the  Clinical  Directorates  via  weekly 
clinical  directorate  governance  meetings  and  at  the  monthly  Patient  Safety  Oversight 
Meeting to ensure effective dissemination of the updates 
It  is  planned  to  highlight  the  updated  policy  to  Senior  Leaders  within  the  Risk  and 
Assurance Group scheduled for 15th December 2025  

 

                                                                                            
 
 
 
 
 
 
 
 
 
 
   A safety alert has been published across the whole Trust, to ensure that staff are aware 
of the need to call the EMRT when an immediate/recoverable/un-expected event such as 
choking  or  airway  compromise  –  even  when  a  Do  Not  Attempt  Cardiopulmonary 
Resuscitation  (DNACPR)  is  in  place.    Assurance  has  been  received  from  the  clinical 
directorate representatives at the Patient Safety Oversight Meeting that they are aware of 
the safety alert and have disseminated in their areas 

  A communication bulletin has been released to highlight the policy update to all staff 
  An exercise to align the wording within the EMRT policy and the Treatment Escalation Plan 
policy has been undertaken to provide consistency in language across both policies to 
reduce confusion for staff and reinforce the required message to staff 

To address the concerns related to the SALT assessment requirements, we have undertaken the 
following:  

  Commenced a cascade training programme to have swallowing safety cascade trainers 
for each ward area, who are responsible for training their ward teams. To date 44 nurses 
have been trained in this role.  

  As  a  priority  ALL  emergency  admissions  routes  now  have  swallowing  safety  cascade 

trainers in place.  

  80% of nursing and HCA staff in our ED department have received AT LEAST one form of 

direct training in swallowing awareness  

  We  deliver  training  on  the  new  junior  doctor  induction  programme  bi-annually  (each 

intake) 

  Referrals to SALT continue to be available  
  Dysphagia guideline has been re-circulated to all clinical directorates  
  Dysphagia  guideline  is  available  on  the  policy  platform  to  ensure  availability  when 

required by all staff  

  Online training available to all staff for swallowing assessment  
  Swallowing assessment/Nutritional assessment is the topic of a planned safety bulletin 

to be circulated in December  

I trust this information will provide you with reassurance regarding the concerns raised in your 
report, however, if I can assist with anything further, please do not hesitate to contact me.  

Yours sincerely, 

Group Chief Executive