Andrew Tizard-Varcoe

28 May 2025 

Mr P Spinney 
HM Senior Coroner 
The County of Devon, Plymouth 
and Torbay 
c/o Devon Coroners Court 

Sent via email to  

Dear Mr Spinney 

Trust Management Office
Musgrove Park Hospital

Barton House South  

Parkfield Drive
Taunton
TA1 5DA

REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Andrew Tizard-Varcoe 

I am writing in response to your correspondence dated 31 March 2025 regarding the Regulation 
28 Notice of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the 
death of Andrew Tizard-Varcoe which concluded on 27 March 2025.  

We have set out the matters of concern as raised in the report below and our response to them.  

MATTERS OF CONCERN 

1. 

Consideration should be given to reviewing the process of managing and treating 
patients with multiple health conditions, being treated across different hospital 
trusts, to ensure greater coordination, collaboration and optimal treatment. 

It would be unusual to undertake shared care between two neighbouring departments 
unless specifically requested. It is normally best practice for the same clinical consultant 
and team to manage care and treatment of a patient (where possible) for continuity.  ENT 
and other specialties often work closely and collaboratively with colleagues from other 
NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient 
treatment and this generally works well.  Where SFT input is needed, we have and will 
continue to work with partners to ensure coordination, collaboration and optimal treatment 
in the best interests of the patients and their families  

There are areas within the Trust that do work across more than one NHS Trust, such as 
vascular surgery, and they have a shared care agreement as part of a hub and spoke 
agreement, where SFT is the hub. This does allow access for all partners involved to 
certain medical records across the whole pathway, but we recognise this is harder to 
achieve in organisations, such as ours, where not all medical records are on the same 
electronic system.  

Funding for integrated IT systems across organisations is something beyond the control 
of SFT but we are working with the NHS Somerset Integrated Care Board and the 
national team to develop an integrated Electronic Health Record across acute, community 
and mental health services in Somerset which will support better integration and 
interaction across our services as well as with neighbouring trusts and systems. 

Within the Trust we do have the complex care team who provide support to people with 
complex health and social care needs, often working in an integrated neighbourhood 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 team model. These teams aim to improve care, reduce hospital visits, and empower 
individuals to manage their health and live as independently as possible. They offer 
various services, including care planning, coordination, and support for families and 
carers.  

2. 

Consideration should be given to reviewing arrangements for follow-up outpatient 
appointments in the ear, nose and throat departments in the Royal Devon 
University Healthcare NHS Foundation Trust and the Somerset NHS Foundation 
Trust, to ensure effective monitoring. 

Our ENT waiting list is monitored daily with close working between our 
Admissions/Booking Team and the ENT operational team. There is a weekly Patient 
Tracking List meeting where the waiting list is reviewed in a wider group. There is also a 
biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and 
Operational management) around the outpatient demands and the areas of concerns. 
Discussions are then had with our operational team, rota coordinator and the clinicians 
around changing activity to meet the demand where possible. We have undertaken a 
review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it 
can be demonstrated that regular correspondence is occurring with less than 4 weeks 
between patient and service contact over a 6–8-month period. 

I hope that the above information has been helpful. Can I also take this opportunity to express 
my condolences to Mr Tizard-Varcoe’s family for their loss. 

Please do not hesitate to contact me if you require any further information. 

Your sincerely 

CHIEF EXECUTIVE 
Somerset NHS Foundation Trust

Mr P Spinney 
Coroner 

27 May 2025 

Dear Mr Spinney 

Royal Devon and Exeter 
Hospital (Wonford) 
Barrack Road 
Exeter 
EX2 5DW 

CHIEF EXECUTIVE’S OFFICE 

Direct Dial: 

Email: 

I  am  writing  further  to  the  Regulation  28  Report  issued  on  31  March  2025  following  the  inquest 
touching the death of Mr Andrew Tizard-Varcoe.   

Your raised three areas in which you considered action should be taken: 

1.  Consideration should be given to reviewing the process of managing and treating patients 
with  multiple  health  conditions,  being  treated  across  different  hospital  trusts,  to  ensure 
greater coordination, collaboration and optimal treatment.  

2.  Consideration  should  be  given  to  reviewing  arrangements  for  follow-up  outpatient 
appointments  in  the  ear,  nose  and  throat  departments  in  the  Royal  Devon  University 
Healthcare  NHS  Foundation  Trust  and  the  Somerset  NHS  Foundation  Trust,  to  ensure 
effective monitoring.  

3.  Royal  Devon  University  Healthcare  NHS  Foundation  Trust  to  consider  reviewing  the 
arrangements for patient discharge in circumstances where a patient is being treated across 
different  specialisms,  to  ensure  that  there  is  consultant  oversight  in  all  areas  of  ongoing 
treatment. 

I will address each of these in turn.  

Consideration should be given to reviewing the process of managing and treating patients 
with  multiple  health  conditions,  being  treated  across  different  hospital  trusts,  to  ensure 
greater coordination, collaboration and optimal treatment.  

Mr  Tizard-  Varcoe  received  treatment  from  April  2021  –  May  2022  at  both  North  Devon  District 
Hospital and Royal Devon and Exeter Hospital which were, for most of that time, part of different 
hospital Trusts. However, it is worth clarifying that at the time, the ENT service was a single service 
across both sites although they were different hospital trusts.  ENT has been a single service (based 
in  East  with  clinics  in  Barnstaple  and  community  locations) since  2016.  The main  issue  was  the 
different  medical  record systems  that  were  in  use  at the  time. The  clinicians  who  saw  Mr  Tizard-
Varcoe at these hospitals were from the same treating team but it is acknowledged that the medical 
records systems were different, and this did not provide optimal care for patients.   

Chief Executive Officer: 

                                  Chair: Dame 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  April  2022,  the  two  Trusts  formally  merged  creating  Royal  Devon  University  Healthcare  NHS 
Foundation Trust and by July 2022, both sites and all staff were using the same electronic records 
system  (EPIC).  This  use  of  the  one  combined  patient  record  has  significantly  improved  care  for 
patients receiving care across both sites and this has been a significant and important change since 
Mr Tizard-Varcoe’s death.  

A significant driver for this merger was to help address some of the issues encountered by Mr Tizard-
Varcoe especially in providing significantly more joined up care for patients across the two sites.  

As part of the Integration Programme a detailed exercise was undertaken to identify and agree the 
core  principles  which  would  underpin  any  decisions  made  during  the  integration  of  teams  and 
services.  These are as follows:  

•  This will be a clinically-led programme of work across North and East 
•  There will be equity of access for our population across Northern and Eastern Devon, without 

diminishing the quality of care where the service functions well 

•  To view each specialty as a single service 
•  To keep as many clinical specialties at the North site as possible and develop high quality 

handover of care to specialist teams where this cannot be provided  

•  To optimise the use of technology to support remote advice and decision making to enhance 

and maintain the provision of clinical services across the multiple sites 

•  The solutions described must work for clinicians at both sites 

(Integration Patient Benefit, 2022 )  

I am assured that since the merger of the two Trusts and the implementation of Epic in across both 
sites and, continuity of care and patient safety has been improved.  

Many specialist healthcare services (such as ENT and vascular services used by Mr Tizard Varcoe) 
are now provided in increasingly more specialist centres nationally. The ENT service was specifically 
mentioned in the merger business case as a service that had an existing Service Level Agreement 
with the RDE pre-merger but would be strengthened by the levers that being one organisation and 
one team would bring. 

At the moment, patients attending our Northern services who require vascular care are referred to 
Musgrove Park Hospital in Taunton and not to the RD&E in Exeter. This is a commissioning decision 
and so the decision of where to refer such patients sits with the commissioners and is not something 
I have influence over. However, we will review whether complex patients like Mr Tizard-Varcoe (who 
are  receiving  care  under  numerous  specialities within  RDUH)  can  be  seen  in  Exeter for  vascular 
issues.  

It is accepted that the above changes described will not necessarily improve coordination with those 
patients receiving care across Somerset and Devon. However, there is a planned move across the 
whole  of  Devon  itself  (to  include  Torbay  and  Plymouth  Hospitals)  to  use  one  electronic  patient 
records system and this is due to go live in Torbay in April 2026 and in Plymouth in July 2026 which 
will again improve the coordination of care for all patients across Devon.  

The introduction of nationwide records system it is outside of my remit and this should be addressed 
to NHS England. However, I can reassure you that there has been and there is ongoing significant 
change  across  the  whole  of  Devon  which  will  improve  coordination,  collaboration  and  optimal 
treatment of patients across the county.  

Consideration  should  be  given  to  reviewing  arrangements  for  follow-up  outpatient 
appointments  in  the  ear,  nose  and  throat  departments  in  the  Royal  Devon  University 
Healthcare  NHS  Foundation  Trust  and  the  Somerset  NHS  Foundation  Trust,  to  ensure 
effective monitoring.  

Chief Executive Officer: 

                                  Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a 
relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings 
were made.  I can reassure you that over the past few years, a significant amount of work has gone 
into improving booking processes and waiting list (workqueue) monitoring. There is now much more 
robust ongoing validation/ assurance of booking processes and waiting lists.  

These  changes  include  monthly  dashboard  meetings  with  the  bookings  team  and  the  senior 
operations manager of the specialty. At these meetings, the number of overdue follow ups and the 
capacity to see patients are reviewed so that clinical capacity can be made available and to ensure 
patients are seen within recommended clinical time frame.  

Another one of the changes that has been implemented is that the use of the EPR system has been 
further developed to include a “fast pass” and “ticket scheduling system” that sends out any vacant 
slots to the patients suitable for booking up to 6 times daily via the MyCare (EPR) app until the slots 
are filled. Patients can bring pre-booked appointments forward to a closer date.  

Ticket scheduling is another change due to be brought in which will be a virtual booking system on 
our  MyCare  app.  This  feature  will  send  out  notifications  to  the  patients  inviting  them  to  book  an 
appointment,  the  app  will  present  all  available  slots  to  the  patient  for  booking.  All  bookings  are 
completed and confirmed via the app. Any patients without the app will still be sent standard letters 
inviting them to clinic. This will avoid patients having to call into the office for an appointment which 
will be much faster.  

In  terms  of  the  ongoing  validation,  there  is  a  new  column  on  work  queue  (waiting  lists)  showing 
expected dates of next appointment and the percentage overdue which better reflects the urgency 
of a patient’s appointment to allow these to better managed. Further, there are also more staffing at 
the central booking office enabling more effective validation using these tools on the EPR.  

Because of all these changes, we are assured that the majority of patients are being seen within the 
recommended clinical time frames and the tools for booking and monitoring of this are more robust. 
There are occasions when this does not happen due to lack of capacity in clinics and because some 
patients don’t respond to our invitations to contact us to book their appointment, but the service is 
now aware of these patients and action is taken to ensure they are seen as soon as possible.  
The above changes which have already taken place since Mr Tizard-Varcoe’s death, and those due 
to come in, assure me that significant work has been done to improve ENT outpatient follow up and 
that these follow ups are monitored efficiently.  

Royal  Devon  University  Healthcare  NHS  Foundation  Trust  to  consider  reviewing  the 
arrangements for patient discharge in circumstances where a patient is being treated across 
different  specialisms,  to  ensure  that  there  is  consultant  oversight  in  all  areas  of  ongoing 
treatment. 

At the time of Mr Tizard-Varcoe’s admission in October – November 2021, he was discharged while 
under the care of the ENT Team. The discharge summary was written by a respiratory physician as 
a  large  proportion  of  Mr  Tizard  -Varcoe’s  care  was  provided  by  the  respiratory  team  during  his 
admission. However, the error in not prescribing the antibiotics did not sit with that doctor and the 
respiratory  team.  The  decision  to  stop  the  antibiotics  was  made  by  a  junior  ENT  doctor 
misinterpreting  the  advice  of  the  ENT  Consultant  and  Microbiologists.  He  should  have  been 
discharged with antibiotics but these were discontinued by the ENT junior doctor. 

Chief Executive Officer: 

                                  Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant 
that  not  every  discharge  could  be  reviewed  by  a  named  Consultant.  Since  2022,  a  further  two 
permanent ENT Consultants have been appointed. This has allowed to the team to have a named 
consultant ward round on a daily basis and this means there is now senior supervision of decision 
making on every ward round. This includes reviewing all patients due to be discharged as well as 
their management plan on discharge. With this now in place, I am assured that there would be senior 
oversight  of  ongoing treatment  and  patients  such  as  Mr  Tizard-Varcoe would  be  discharged  with 
appropriate treatment plans in place.  

I hope the above information is helpful and addresses the concerns you have raised. Please do let 
me know if you have any further questions and I will be very happy to assist. 

Yours sincerely 

CHIEF EXECUTIVE OFFICER    

Chief Executive Officer: 

                                 Chair: