Maureen Batchelor

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Maureen Brenda Batchelor who died on 26 February 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 August 2025 concerning the death of Maureen Brenda Batchelor on 26 February 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Maureen’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Maureen’s care have been listened to and reflected upon.

Your report raises concerns around patients being moved to and treated in the corridor when the Emergency Department (ED) has reached capacity, and the rising use of corridors to care for patients across the country due to insufficient space within the ED.

The delivery of care in Temporary Escalation Spaces (TES) in EDs experiencing patient crowding (including providing care at beds and chairs) is not acceptable and should not be considered as standard. TES refers to care given in any unplanned settings (such as corridors) and, in September 2024, NHS England published a set of principles for supporting improved quality of care should patient demand outstrip capacity. 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 June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. 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 National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

16th October 2025

are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.

Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.

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 Maureen, 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.

Dear Ms Andrews Inquest into the death of Maureen Brenda Batchelor Thank you for your letter of 5 August 2025, enclosing your formal report under Regulation 28 to Prevent Future Deaths, to NHS England & NHS Improvement, the Department of Health and Social Care, and the Trust. At the outset, I wish to express my sincere condolences to family. Thank you for confirming that there was no evidence from which you could conclude that the period of time taken to transfer Mrs Batchelor from the corridor to the Resuscitation However, you are understandably concerned that the corridor at times continues to be used to treat patients when there is insufficient capacity in within the Emergency Department (ED). Your Regulation 28 report has been carefully considered by the Executive team, and the Medicine Division, including the Chief of Service for Medicine and the Divisional Director of Nursing for Medicine. Your concerns have also been shared at the Trust wide Patient Safety Group meeting to ensure widespread learning and engagement. As you know from the evidence heard at the inquest, the Medicine Divisional Leadership team, the Hospital Directors, and Executive team are continuously working on several separate but linked workstreams, which were previously in their infancy, to eradicate the use of the ED corridor for patient care and ensure they are treated in the most appropriate clinical environment with dignity and without delays. Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County Hospital, is well underway.

[Page 2] Our Interim Assistant Director for Leadership and Management is leading on a cultural nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change. We now have a Direct to specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day. We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes: 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) Virtual Health, both General Virtual Ward and Respiratory Home Monitoring Services Frailty and Respiratory SDEC (Same Day Emergency Care) Optimisation Interprofessional Standards UTC (Urgent Treatment Centre) Optimisation Early Discharge Planning Deconditioning Prevention Tiered Acuity Model These initiatives are in collaboration with our colleagues from the ICB (Integrated Care Board), Sussex Community NHS Foundation Trust (SCFT), South East Coast Ambulance Service (SECAmb), Sussex Partnership NHS Foundation Trust (SPFT), and Brighton & Hove City Council (BHCC). I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8 -10 ambulance attendances are avoided each day. Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible. One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.

[Page 3] We have changed our Medical Model of Care in ED so there is a GP of the day supporting our ambulatory patient area. There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand. We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space. The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward. I hope this letter provides assurance that we are continuing to make significant improvements to the quality and safety in the Royal Sussex County Hospital ED.

Dear Ms Andrews Inquest into the death of Maureen Brenda Batchelor Thank you for your letter of 5 August 2025, enclosing your formal report under Regulation 28 to Prevent Future Deaths, to NHS England & NHS Improvement, the Department of Health and Social Care, and the Trust. At the outset, I wish to express my sincere condolences to family. Thank you for confirming that there was no evidence from which you could conclude that the period of time taken to transfer Mrs Batchelor from the corridor to the Resuscitation However, you are understandably concerned that the corridor at times continues to be used to treat patients when there is insufficient capacity in within the Emergency Department (ED). Your Regulation 28 report has been carefully considered by the Executive team, and the Medicine Division, including the Chief of Service for Medicine and the Divisional Director of Nursing for Medicine. Your concerns have also been shared at the Trust wide Patient Safety Group meeting to ensure widespread learning and engagement. As you know from the evidence heard at the inquest, the Medicine Divisional Leadership team, the Hospital Directors, and Executive team are continuously working on several separate but linked workstreams, which were previously in their infancy, to eradicate the use of the ED corridor for patient care and ensure they are treated in the most appropriate clinical environment with dignity and without delays. Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County Hospital, is well underway.

[Page 2] Our Interim Assistant Director for Leadership and Management is leading on a cultural nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change. We now have a Direct to specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day. We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes: 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) Virtual Health, both General Virtual Ward and Respiratory Home Monitoring Services Frailty and Respiratory SDEC (Same Day Emergency Care) Optimisation Interprofessional Standards UTC (Urgent Treatment Centre) Optimisation Early Discharge Planning Deconditioning Prevention Tiered Acuity Model These initiatives are in collaboration with our colleagues from the ICB (Integrated Care Board), Sussex Community NHS Foundation Trust (SCFT), South East Coast Ambulance Service (SECAmb), Sussex Partnership NHS Foundation Trust (SPFT), and Brighton & Hove City Council (BHCC). I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8 -10 ambulance attendances are avoided each day. Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible. One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.

[Page 3] We have changed our Medical Model of Care in ED so there is a GP of the day supporting our ambulatory patient area. There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand. We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space. The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward. I hope this letter provides assurance that we are continuing to make significant improvements to the quality and safety in the Royal Sussex County Hospital ED.