NHS England
NHS / Health Body
Noted
NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Samsam Haji Ali Ateye who died on 12 May 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 September 2024 concerning the death of Samsam Haji Ali Ateye on 12 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samsam’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Samsam’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Samsam’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns over the policy for testing for COVID-19 before cardiac surgery, specifically valve replacement surgery.
NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022. This can be found here: NHS England » COVID-19 standard operating procedure: testing for elective care pre-admission patient
The document advises that a risk-based approach should be taken between patients and clinical teams in all cases, including where test results are positive. Individual NHS Trusts are responsible for implementing and following processes to manage COVID- 19 risks and appropriately consent patients.
This approach is reflective of guidance (second version published in February 2022 and latest version published in June 2023) by The Association of Anaesthetists, Federation of Surgical Speciality Associations, Royal College of Anaesthetists, and the Royal College of Surgeons. Both versions make clear the need for risk assessment to balance the risks of proceeding with surgery versus postponement, considering the severity of the patient’s illness/condition and the severity of their COVID-19 infection.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22 November 2024
NHS England notes that the Royal Brompton & Harefield NHS Foundation Trust, where Samsam underwent her surgery, published a COVID-19 and heart surgery Patient Information Leaflet in May 2020. This states that where patients receive positive COVID-19 test results, transfer to Harefield Hospital cannot happen straightaway, and that an expert panel will review cases where delaying operations poses a high risk. It is difficult for NHS England to provide further comment on Samsam’s care from the information in your Report and it is not clear why the operation went ahead before the results of the second COVID-19 PCR test were known. I would therefore refer the Coroner to the Trust for further information and for their most up- to-date position on COVID-19 pre-operative testing.
I would also like to provide further assurances on 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 Samsam, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 September 2024 concerning the death of Samsam Haji Ali Ateye on 12 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samsam’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Samsam’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Samsam’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns over the policy for testing for COVID-19 before cardiac surgery, specifically valve replacement surgery.
NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022. This can be found here: NHS England » COVID-19 standard operating procedure: testing for elective care pre-admission patient
The document advises that a risk-based approach should be taken between patients and clinical teams in all cases, including where test results are positive. Individual NHS Trusts are responsible for implementing and following processes to manage COVID- 19 risks and appropriately consent patients.
This approach is reflective of guidance (second version published in February 2022 and latest version published in June 2023) by The Association of Anaesthetists, Federation of Surgical Speciality Associations, Royal College of Anaesthetists, and the Royal College of Surgeons. Both versions make clear the need for risk assessment to balance the risks of proceeding with surgery versus postponement, considering the severity of the patient’s illness/condition and the severity of their COVID-19 infection.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22 November 2024
NHS England notes that the Royal Brompton & Harefield NHS Foundation Trust, where Samsam underwent her surgery, published a COVID-19 and heart surgery Patient Information Leaflet in May 2020. This states that where patients receive positive COVID-19 test results, transfer to Harefield Hospital cannot happen straightaway, and that an expert panel will review cases where delaying operations poses a high risk. It is difficult for NHS England to provide further comment on Samsam’s care from the information in your Report and it is not clear why the operation went ahead before the results of the second COVID-19 PCR test were known. I would therefore refer the Coroner to the Trust for further information and for their most up- to-date position on COVID-19 pre-operative testing.
I would also like to provide further assurances on 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 Samsam, 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.