Department of Health and Social Care
Central Government
Action Taken
The University Hospitals of Leicester NHS Trust has changed its process for emergency theatre booking and improved documentation. A Patient Safety Incident Investigation (PSII) is underway, and the Trust is exploring expansion of theatre capacity through a 'surgical hub' programme. (AI summary)
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Dear Mrs Hocking,
Thank you for the Regulation 28 report of 10 December 2024 sent to the Department of Health and Social Care about the death of Karen Dack. I am replying as the Minister with responsibility for Health (Secondary Care).
Firstly, I would like to say how saddened I was to read of the circumstances of Karen Dack’s death, and I offer my sincere condolences to Karen’s 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 Karen Dack’s last minute surgery cancellations. This happened on three separate occasions following emergency admission due to lack of theatre availability. See ‘matters of concerns’ outlined in the PFD report.
In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. NHS England has raised your concerns directly with the Integrated Care Board (ICB) relevant to this case (NHS Leicester, Leicestershire and Rutland ICB).
Prior to the issuing of the Regulation 28, the Trust had completed a mortality review and identified some immediate actions that were instigated to reduce future risk. These included a change to the process for emergency theatre booking and improvements in tallying documentation across different systems. University Hospital of Leicester NHS Trust’s (UHL) clinical teams are fully focused on ensuring that the acute deterioration of patients is acted on promptly and their senior clinical decision makers act in a manner to ensure appropriate clinical risk is balanced with operational pressures.
The case also met the national criteria for a Patient Safety Incident Investigation (PSII), and this is being undertaken in the Trust. NHS Leicester, Leicestershire and Rutland ICB is engaging with the Trust and awaits the outcome of the PSII. Regarding your concern over theatre capacity, the Trust are focussing on fully utilising all elective theatre capacity, to free up theatre capacity for urgent care; notably at Loughborough, Melton and the new East Midlands Planned Care Centre at the Leicester General Hospital site. Additionally, a new day-case theatre is replacing an old dormant facility at Hinckley, with the build due in 2026. All of this should allow activity to be undertaken more efficiently within the capacity available and free up time for the larger or more urgent cases in the most appropriate acute setting. The Trust is exploring expansion of theatre capacity through the ‘surgical hub’ programme. Dedicated and protected surgical hubs transform the way the NHS provides elective care by focusing on providing high volume low complexity surgery, as recommended by the Royal College of Surgeons of England. NHS England are also undertaking a thorough investigation of this case under the Patient Safety Incident Response Framework (PSIRF) process to ensure learning is taken from this case going forward. NHS England will also be flagging this Regulation 28 through to their Quality Committee this month. This case will also be taken to the Leicester, Leicestershire and Rutland (LLR) system-wide Learning from Deaths forum, chaired by the ICB Deputy Medical Director to ensure learning is shared across the system. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 10 December 2024 sent to the Department of Health and Social Care about the death of Karen Dack. I am replying as the Minister with responsibility for Health (Secondary Care).
Firstly, I would like to say how saddened I was to read of the circumstances of Karen Dack’s death, and I offer my sincere condolences to Karen’s 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 Karen Dack’s last minute surgery cancellations. This happened on three separate occasions following emergency admission due to lack of theatre availability. See ‘matters of concerns’ outlined in the PFD report.
In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. NHS England has raised your concerns directly with the Integrated Care Board (ICB) relevant to this case (NHS Leicester, Leicestershire and Rutland ICB).
Prior to the issuing of the Regulation 28, the Trust had completed a mortality review and identified some immediate actions that were instigated to reduce future risk. These included a change to the process for emergency theatre booking and improvements in tallying documentation across different systems. University Hospital of Leicester NHS Trust’s (UHL) clinical teams are fully focused on ensuring that the acute deterioration of patients is acted on promptly and their senior clinical decision makers act in a manner to ensure appropriate clinical risk is balanced with operational pressures.
The case also met the national criteria for a Patient Safety Incident Investigation (PSII), and this is being undertaken in the Trust. NHS Leicester, Leicestershire and Rutland ICB is engaging with the Trust and awaits the outcome of the PSII. Regarding your concern over theatre capacity, the Trust are focussing on fully utilising all elective theatre capacity, to free up theatre capacity for urgent care; notably at Loughborough, Melton and the new East Midlands Planned Care Centre at the Leicester General Hospital site. Additionally, a new day-case theatre is replacing an old dormant facility at Hinckley, with the build due in 2026. All of this should allow activity to be undertaken more efficiently within the capacity available and free up time for the larger or more urgent cases in the most appropriate acute setting. The Trust is exploring expansion of theatre capacity through the ‘surgical hub’ programme. Dedicated and protected surgical hubs transform the way the NHS provides elective care by focusing on providing high volume low complexity surgery, as recommended by the Royal College of Surgeons of England. NHS England are also undertaking a thorough investigation of this case under the Patient Safety Incident Response Framework (PSIRF) process to ensure learning is taken from this case going forward. NHS England will also be flagging this Regulation 28 through to their Quality Committee this month. This case will also be taken to the Leicester, Leicestershire and Rutland (LLR) system-wide Learning from Deaths forum, chaired by the ICB Deputy Medical Director to ensure learning is shared across the system. I hope this response is helpful. Thank you for bringing these concerns to my attention.