Norma Campbell

Trust Headquarters  
Executive Offices 

Ground Floor                                 

Pathology and Pharmacy Building 

The Royal London Hospital                    

 80 Newark Street 
London 
E1 2ES 

Our ref:   
Your ref:  

Date: 31 July 2025 

Private & Confidential 

East London Coroners Court 
Queens Road 
Walthamstow 
London 
E17 8QP 

Dear HM Coroner, 

Thank  you  for  your  letter  dated  16th  June  2025  following  the  inquest  of  Mrs  Norma  Faye 
Campbell  detailing  concerns  arising  from  the  evidence  presented  and  inviting  the  Trust  to 
consider the implementation of changes to reduce the risk of future harm or death.  

The  Prevention  of  Future  Death  report  has  been  reviewed  at  Whipps  Cross  Divisional  and 
Hospital Boards to agree actions that will have an impact across the Barts Health group.  The 
PFD  and  response  will  be  shared  at  Trust  Safety  Committee,  with  National  Health  Service 
England (NHSE), the Care Quality Commission (CQC) and the North East London Integrated 
Care Board.  

Your concerns  

1.  The  inquest  heard  that  the  A&E  department  at  Whipps  Cross  Hospital  often  has 
inadequate staffing and medical facilities to address the patient numbers and acuity. The 
inquest heard that overcrowding in A&E is a national concern.  

2.  The inquest heard that it is not uncommon to find patients in corridors when they need 
to  be  monitored.  On  the  13  January  2024  there  were  more  than  25  patients  in  the 
corridors. They were not receiving an appropriate level of care.  

3.  There  are  often  insufficient  numbers  of  resuscitation  beds.  Patients  who  require  a 
resuscitation area level of care are often directed to the majors area of A&E. The majors 
area lacks the levels of staffing and lacks the monitoring equipment required to treat this 
cohort of patients. In the absence of increased numbers of resuscitation beds, a system 
for continuous monitoring of observations in majors would significantly improve patient 
care.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  There is no electronic observation system in place within the A&E department of Whipps 
Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not 
therefore automatically brought to the attention of clinical supervisors.  

5.  The Critical Care Outreach Team (CCOT) do not currently attend A&E for deteriorating 
patients. The overcrowding and lack of resourcing in A&E highlights the need for the 
CCOT to provide support to A&E patients as well as patients on the ward. 

Our response 

The Trust deeply regret the concerns raised by HM Coroner and the impact the inquest findings 
will have had on the patient’s family.  

As part of the ongoing review of the Urgent and Emergency Care pathway at Whipps Cross 
Hospital, a weekly  committee chaired by 
, Chief Executive at Whipps Cross 
Hospital commenced in February 2025 to look at the issues in the Emergency Department and 
our  inpatient  wards.  This  committee  addresses  the  issues  around  overcrowding,  the 
reconfiguration  of  the  department  and  how  the  hospital  will  tackle  “exit  block”  from  the 
Emergency  Department  which  are  referenced  by  the  concerns  you  have  raised.  Whilst  this 
committee looks at the overall issues (with quality improvement workstreams looking at different 
areas) the Trust also acknowledges the specific concerns that we have addressed below. 

Inadequate staffing. 

In May 2024, the Hospital Executive Board at Whipps Cross Hospital approved the increase in 
whole time equivalent (WTE) medical staff from 43 WTE to 63 WTE. This was an increase in 
1.1  WTE  consultants,  10  WTE  Tier  A  (registrar)  grade  residents  and  5  additional  Paediatric 
Emergency  residents  (4  at  registrar  grade  and  1  at  senior  house  officer  grade).  In  addition, 
locum shifts equivalent to 5 WTE were also approved as part of the staffing to ensure that the 
department was appropriately always staffed. Recruitment has been ongoing since June 2024 
and for August 2025, the agreed establishment will be fully recruited for resident doctors with 
successful interviews for the consultant grades on 17th July 2025. This brought Whipps Cross 
into line with the other Emergency Departments within Barts Health for medical staffing. 

For nursing staff, the Hospital Executive Board has approved an increase in 10.5 WTE nursing 
staff in line with the Safer Nursing Care Tool review of staffing and is currently in the process of 
recruiting to these posts. 

Both the medical and nursing staffing remain under review by the Hospital and Trust to ensure 
that these increases in staffing meet the needs for the patients that we care for in the Emergency 
Department (this includes a further staffing review of the consultant tier which should help align 
our staffing numbers with similar hospitals of acuity).   

Overcrowding / Corridor Care 

The Trust acknowledges that the Emergency Department does get overcrowded and at present 
some  patients  are  cared  for  in  a  corridor,  particularly  in  the  “Emergency  Assessment”  area 

 
 
 
 
 
 
 
 where  patients  arriving  by  ambulance  are  reviewed  when  they  arrive  at  the  Emergency 
Department. This is reflected by the risk assessment by the Trust rating the risk of overcrowding 
in the Emergency Department at 20 (high risk). 

Where we do have days that there is overcrowding within the Emergency Department, additional 
nurses are redeployed to provide “fundamentals of care” and care for the patients waiting to be 
admitted  to  the  hospital.  In  winter 2024/2025  an  additional 17  bedded  “temporary escalation 
space” was opened with dedicated nursing and medical staff next to the Emergency Department 
to care for patients who required admission to hospital and had already commenced treatment 
to free up space within the Emergency Department for patients who were requiring assessment. 

The Trust has committed to reconfiguring the Emergency Department at Whipps Cross Hospital. 
Work  to  do  this  has  commenced  and  is  due  to  be  fully  completed  in  March  2026.  This  will 
reconfigure the current Emergency Assessment area from 4 cubicles and some corridor space 
to a dedicated 14 trolley assessment area (this work is due to be completed by January 2026) 
and remove the current corridor space. 

There is also ongoing work across the hospital to reduce length of stay on the wards and prevent 
“exit block” from the Emergency Department. This includes a Quality Improvement programme 
around  the  use  of  electronic  whiteboards,  a  dedicated  workstream  about  discharge  and  a 
regular systems oversight meeting that looks at how health and social care organisations across 
Waltham Forest and Redbridge can work together to reduce delays in discharge. 

Looking at the Summary Acute Medicine Indicator Table (SAMIT) data for April 2025 compared 
to April 2024 the average length of stay in the hospital has dropped from 13.4 days to 10.9 days 
and we are committed to work to continue to reduce this and thus reduce overcrowding in the 
Emergency Department. 

Insufficient Numbers of Resuscitation Beds 

There is currently a mismatch between the number of resuscitation beds and the demand placed 
on  them  at  peak  times  in  the  Emergency  Department.  Although  we  have  six  resuscitation 
cubicles, which is close to what would be expected for our population, operational realities—
such as surges in ambulance arrivals and deterioration of walk-in patients—often exceed this 
capacity. 

A major contributing factor is exit block: patients who are clinically ready to be stepped down 
cannot  be  moved  due  to  lack  of  downstream  bed  availability.  This  leads  to  unnecessary 
occupancy of resuscitation beds and reduces capacity for new critically ill arrivals.   The works 
that are ongoing to help alleviate this pressure have already been mentioned above.    

We have planned infrastructural improvements, including a new centrally located resuscitation 
area near assessment zones, which is expected to enhance flow.  

Additionally,  enforcing  internal  professional  standards,  such  as  mandatory  consultant-to-
consultant handovers, will support faster decision-making and reduce unnecessary delays in 
the  resus  area  is  something  that  the  senior  leadership  team  within  the  hospital  is  actively 

 
 
 
 promoting.   Furthermore, having the increased staffing as mentioned above will also help to 
address decision making and facilitate more timely treatment and decision for safer disposition 
to other areas of the hospital. 

These  changes  are  aimed  at  aligning  resuscitation  bed  capacity  more  closely  with  real-time 
demand, improving both patient safety and departmental efficiency. 

No Electronic Observation System within the Emergency Department 

In 2024 the Trust upgraded the electronic patient record in the Emergency Department to the 
“Launchpoint”  system  provided  by  Oracle  and  purchased  in  May  2024  an  additional  49 
observations machines that directly relay clinical observations to the electronic patient record. 

The observations and Early Warning Scores (EWS) are then displayed on the overview panel 
for  each  clinical  area  within  the  department  (and  all  patients  can  also  be  viewed  within  the 
department if that option is selected). The nurse in charge and senior doctor for each clinical 
area now have an overview of each patient within the area they have clinical responsibility for 
during their shift. An example of the view is shown below. 

The Critical Care Outreach Team (CCOT) do not attend the Emergency Department. 

We would like to acknowledge and address the concern raised about the absence of a formal 
CCOT  presence  in  the  Emergency  Department.  CCOT  do  not  currently  have  the  skill  set  or 
resource  to  review  acutely  unwell  and  undifferentiated  patients  within  the  emergency 
department. An extended period of training would be required which will need to be determined 
by local service needs and referenced to outreach services that have successfully implemented 
this. However, we recognise the importance of timely critical  care input and have alternative 
arrangements  to  ensure  support  is  available  when  needed.  The  current  pathway  is  that  the 
critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care 
unit, is available to attend the ED, this registrar has access to a consultant intensivist at any 

 
 
 
 
 time  of  the  day.  While  this  arrangement  does  not  replace  a  full  CCOT  presence,  it  ensures 
responsive critical care support to the ED team on request.  

Whipps Cross Hospital teams are committed to preventing avoidable harm to patients and would 
like  to  thank  the  Campbell  family  and  HM  Coroner  for  highlighting  a  gap  in  governance 
processes.  We  hope  that  this  response  provides  assurance  around  the  actions  that  will  be 
completed and monitored to effect improvement in response to this PFD. 

If you have any queries, please do not hesitate to contact me. 

Yours sincerely 

Group Chief Medical Officer 
Barts Health NHS Trust