NHS England
NHS / Health Body
Action Planned
NHS England references the Long-Term Workforce Plan and actions to increase domestic education, training, and recruitment, as well as improve culture and retention. The response also highlights the use of AI and investment in pathology and imaging networks to increase productivity. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Alan Andrew Soane who died on 26 June 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 April 2024 concerning the death of Alan Andrew Soane on 26 June 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Alan’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report and I apologise for any anguish this delay may have caused to Alan’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 that there is a national shortage of Consultant Histopathologists and that this puts a widespread proportion of the patient population at significant risk.
NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 2018 (Care Quality Commission (CQC) Regulation 18) which states that providers must deploy enough National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
18 June 2024
suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements. The Long-Term Workforce Plan also outlines how NHS England will need to take full advantage of digital and technological innovations. This includes using AI diagnostic support to improve accuracy and efficiency of diagnostics in services that include pathology. Investment and support into pathology and imaging networks is ongoing and is expected to increase productivity across imaging and pathology services by up to 10% by March 2025. Since January 2010, there has been a 17% increase to 1,276 in the full-time equivalent of consultant doctors working in the specialty of histopathology within NHS organisations. Data from the General Medical Council also shows that in 2023 there were 506 doctors in histopathology speciality training in England, which is a 32% increase since 2019. My colleagues within the London region are also engaging with North East London Integrated Care Board to ascertain more details about Alan’s care and to gain assurance that learnings have been taken regarding Alan’s incorrect diagnosis and treatment.
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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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 2 April 2024 concerning the death of Alan Andrew Soane on 26 June 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Alan’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report and I apologise for any anguish this delay may have caused to Alan’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 that there is a national shortage of Consultant Histopathologists and that this puts a widespread proportion of the patient population at significant risk.
NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 2018 (Care Quality Commission (CQC) Regulation 18) which states that providers must deploy enough National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
18 June 2024
suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements. The Long-Term Workforce Plan also outlines how NHS England will need to take full advantage of digital and technological innovations. This includes using AI diagnostic support to improve accuracy and efficiency of diagnostics in services that include pathology. Investment and support into pathology and imaging networks is ongoing and is expected to increase productivity across imaging and pathology services by up to 10% by March 2025. Since January 2010, there has been a 17% increase to 1,276 in the full-time equivalent of consultant doctors working in the specialty of histopathology within NHS organisations. Data from the General Medical Council also shows that in 2023 there were 506 doctors in histopathology speciality training in England, which is a 32% increase since 2019. My colleagues within the London region are also engaging with North East London Integrated Care Board to ascertain more details about Alan’s care and to gain assurance that learnings have been taken regarding Alan’s incorrect diagnosis and treatment.
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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.