Philip Unwin

Mr Daniel Howe 
Stoke on Trent and  
North Staffordshire Coroner’s Service 
Stoke Town Hall  
Kingsway 
Stoke-on-Trent 
ST4 1HH  

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

8 April 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Philip John Unwin who 
died on 3 April 2024.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
February 2025 concerning the death of Philip John Unwin on 3 April 2024. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Philip’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the Coroner that the concerns raised about Philip’s care have 
been listened to and reflected upon.   

Your Report raised the concern that Royal Stoke University Hospital’s current model 
of  staffing  within  its  Emergency  Department  (ED)  Resuscitation  area  is  not  in 
compliance with national guidance, and that recommendations made by an internal 
patient safety investigation into Philip’s care have not been implemented.  

NHS  England  has  engaged  with  Staffordshire  and  Stoke-on-Trent  Integrated  Care 
Board  (ICB),  the  responsible  commissioner  for  Royal  Stoke  University  Hospital’s 
urgent and emergency care services, on the concerns raised.  

The ICB advise that the hospital’s Patient Safety Incident Investigation (PSII) focused 
on the issue of failure to manage a deteriorating patient, alongside exploration of the 
current model of care for medical patients within the ED. The investigation found that 
while  nursing  staff  did  undertake  timely  and  appropriate  escalations  of  care  to  the 
various medical teams, it was apparent that robust medical ownership of Philip was 
not  optimal,  leading  to  delayed  escalation  to  the  Intensive  Care  Unit.  From  an 
organisational viewpoint, it was found that the model of care at the time contributed to 
the lack of timely medical intervention for Philip. 

Actions taken to mitigate this risk occurring in the future have included: 

•  The development of a clear process to clarify the escalation process in the ED, 
which  will  provide  assurance  that  for  any  patient  deteriorating  with  the  ED 
footfall there is a clear escalation process for medical and nursing staff. 

•  The development of a process to “ring fence” beds in the Acute Medical Unit 
for acutely unwell patients in the ED who need to be brought to the AMU in a 
timely manner. 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
  
 NHS  England  understands  that  University  Hospitals  of  North  Midlands  NHS  Trust 
(UHNM),  which  Royal  Stoke  University  Hospital  is  a  part  of,  is  in  the  process  of 
reviewing ED resuscitation staffing numbers.  

UHNM advise that having a Named Nurse in the ED has been tried previously at the 
Royal Stoke University Hospital, but a ‘team approach’ has been found to work better 
in  the  Resuscitation  area  of  the  ED  rather  than  care  falling  to  one  medical 
professional. Trauma patients are always nursed 1:1 and this is due to the professional 
judgement  required  and  the  ability  to  flex  staff  around  the  department  and  into 
resuscitation  with  the  support  of  an  Operating  Department  Practitioner  (ODP),  the 
(supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM 
have  asked  us  to  note  that  the  PSII  identified  that  there  was  clear  escalation  by 
relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the 
failure to recognise Philip’s deterioration.  

It  is  appropriate  that  UHNM  provide  any  further  comment  regarding  the  Coroner’s 
concerns.  It  is  NHS  England’s  understanding  that  they  will  be  providing  further 
information on actions taken by the Trust since the inquest into Philip’s death in their 
response to the Coroner.  

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 Philip, 
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

Trust Ref: 

14 April 2025 

STRICTLY PRIVATE & CONFIDENTIAL 
Mr Daniel Howe 
Area Coroner 
Stoke on Trent and North Staffordshire 

Sent via email: 

Dear Mr Howe 

Phillip John UNWIN  

Royal Stoke University Hospital 
Executive Suite 
Springfield 
Newcastle Road 
Stoke-on-Trent 
Staffordshire 
ST4 6QG 

Tel: 01782 676631 

Further  to  your  letter  dated  19  February  2025,  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 Phillip John Unwin.  

Recorded Circumstances of the Death 

Mr Unwin was a 68 years old gentleman who was admitted to Royal Stoke University hospital on 2 April 2024 
at 00:45 due to fever, shortness of breath and chest pain. He was commenced on broad spectrum antibiotics 
within an hour of his arrival for suspected sepsis due to Urinary Tract Infection although it was subsequently 
confirmed that sepsis was secondary to pneumonia. 

He  remained  in  the  resus  area  of  the  Emergency  Department  despite  a  progressive  deterioration  in  his 
condition and escalations from the nursing team to the medical team for him to be reviewed. 

Transfer to ICU was not initiated until approximately 14:30 at which time he was noted to be acutely unwell 
and  in  peri  arrest.  After  being  transferred  to  ICU  at  approximately  16:00  supportive  intervention  including 
sedation,  ventilation  and  vasopressor  medication  failed  to  reverse  his  condition,  and  he  passed  away  in 
hospital on 3 April 2024 due to multi organ failure secondary to pneumonia. 

Concerns 

During  the  course  of  the  inquest,  you  felt  that  evidence  revealed  matters  giving  rise  for  concern.  In  your 
opinion, matters for concern are as follows. 

Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical 
teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation 
area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the 
hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when 
concerns had been raised by staff and family, and that review and escalation to intensive care should have 
been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death). 

. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely 
manner the hospital undertook a Patent Safety Incident Investigation (PSII). As a result of that investigations 
a  number  of  recommendations  were  made  with  assurances  given  to  the  report  author  that  work  is  being 
undertaken  to  review  and  amend  policies  and  procedures  focused  on  reviewing,  escalating  and  referring 
deteriorating patients. 

However, the inquest was told that although the Emergency Department Resuscitation area was where the 
illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The 
Royal  College  of  Emergency  Medicine  (RCEM)  “Nursing  Workforce  Standards  for  Type  1  Emergency 
Departments”  (Appendix  5)  states  “There  will  be  a  minimum  of  Registered  Nurse  to  each  patient  in  the 
resuscitation area”. The recommendation continued that there should be a named nurse allocated to each 

patient which should be 1:1 as per National Guidance. 

The  concern  is  that  the  current  model  of  staffing  within  the  Emergency  Department  Resus  area  is  not  in 
compliance  with  national  guidance  and  the  recommendations  following  internal  investigation  into  the  care 
afforded to the deceased have not been acted upon in this respect. 

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the Coroner’s (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 to which a response is provided below.  

It is correct that the Royal College of Emergency Medicine (RCEM) Nursing Workforce Standards for Type 1 
Emergency Departments states that “there will be a minimum of a Registered Nurse to each patient in the 
resuscitation area.  

The  recommendation  also  provides  that  there  should  be  a  named  nurse  allocated  to  each  patient,  as  per 
National Guidance. 

Royal Stoke Hospital has a Type 1 Emergency Department and has a total of 8 cubicles in the resuscitation 
(resus) area, however the team try to keep resus at a maximum of 6 patients leaving 1 space for paediatric 
emergencies (and when in use paediatric nursing staff from Children’s Emergency Department attend), and 

1 cubicle space for any trauma patients. There are always 4 Nurses who are allocated to the department for 
each  shift  in  resus  and  then  the  department  flexes  our  nurses  to cover  all  Emergency  Department  Areas, 
flexing into the area with the most need at the time.   

Additionally, there is a Operation Department Practitioner (ODP) in the department who supports resus during 
the day, and we also have the ‘outreach team’ who will attend resus whenever there is a trauma call.  When 
acuity or resus capacity is high, the Nurse in Charge (NIC) both supports and makes appropriate staff moves 
from  across  the  whole  of  the  department,  increasing  both  trained  and  untrained  presence  in  resus  on  a 
continual prioritisation of need.   

The overall nurse staffing numbers for the whole of the Emergency Department allow for a degree of flexibility 
across the department to wherever the greatest need is at any one time. Professional clinical judgement allows 
for this decision making, and the NIC remains non-clinical to flex staff as required.   

. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 RCEM guidance is not mandatory and the given the size of the ED at Royal Stoke, our ability to flex our 
nursing team during times of surge, escalation and need is preferred by our ED team on the ground and the 
leadership Triumvirate. This means we continually prioritise through the non-clinical Nurse in Charge so as 
to understand need, and then flex according to skill and priority across our ED. 

We previously trialled a ‘named nurse’ approach within resus and the team felt this lacked flexibility as they 
used an ‘allocated nurse’ based on patient need and skill-set per shift but, following further review, we have 
decided to structure this and reinstate this model to include a ‘named nurse’ within our resus from early April 
2025.  The named nurse model will then be audited/monitored via our internal review processes and as part 
of the Integrated Care Board (ICB) reviews of our Emergency Department. 

We do hope that the above information provides assurance that the Trust has taken the concerns raised at 
the inquest seriously and that both you and Mr Unwin’s family are content with the response that has been 
provided.  

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

Yours sincerely 

Chief Executive 

Chair: David Wakefield 
Chief Executive: Dr Simon Constable 

.