NHS Lancashire and South Cumbria ICB
Integrated Care Board
Action Taken
Lancashire and South Cumbria Integrated Care Board outlines actions taken by Blackpool Victoria Hospital, including revised communication protocols, staff training on triage and escalation, and direct GP referrals. They also detail how the ICB Primary Care Team is involved in communications with General Practices. (AI summary)
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Dear Mr Wilson
Regulation 28 report - Harold Derek Pedley inquest 17 August 2023
Thank you for your letter dated 1 September 2023 sent following the conclusion of the inquest touching the death of Harold Derek Pedley (known as Derek).
I know that you will share my response with Mr Pedley’s family and I first want to express my sincere condolences to them.
Through the Regulation 28 report you have raised three matters of concern relating to the care Mr Pedley received when he attended Blackpool Victoria Hospital; this letter is in response to these issues and I will respond to each matter raised separately.
Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
AND
Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not
Page 2 being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
As you have recognised and in response to the current pressures facing acute trusts (in this case the Emergency Department), NHS England published a revised Operation Pressures Escalation Levels (OPEL) Framework 2023/24 in August 2023. Lancashire and South Cumbria Integrated Care Board (LSC ICB), through its System Co-ordination Centre (SCC), is currently leading a piece of work to implement this new framework consistently across the LSC system by November 2023. In addition to a new methodology for calculating OPEL levels which will allow for greater differentiation of hospitals under pressure, the new framework mandates a series of “action cards” to be implemented at each of the OPEL levels both by the hospital Trust, and by the wider health and care system. These incorporate a range of prescribed actions aimed at reducing the pressure on the hospital, safely improving flow within the hospital and prioritising patient and staff safety; it will be supplemented by locally agreed actions as we work through the implementation. In addition, the updated SCC guidance for Winter 2023 clarifies the role of the SCC in co-ordinating a response across the full LSC system in order to reduce risk in individual Trusts where there is potential to provide support from other providers within the system i.e. mutual aid.
Linked to the OPEL framework described above, where Blackpool Victoria Hospital is under significant pressure, Blackpool Teaching Hospitals will deploy its Full Capacity Protocol to de- escalate and address overcrowding with the Emergency Department, to spread risk, improve flow and keep patients safe. In such circumstances, and where necessary, a multi-agency approach is deployed in the form of tactical command response where health and care partners come together to agree and implement a range of immediate actions to de-escalate the hospital pressures which, for example, may include: freeing community capacity to enable more timely discharges; running multi-agency discharge events; community healthcare staff in-reaching to the Emergency Department to assess for alternative care pathways to prevent admission; and rapid specialty in-reach to urgent and emergency care pathways, so that patients requiring admission are moved from the Emergency Department.
There are significant pressures across urgent and emergency care pathways at Blackpool Victoria Hospital along with the other hospitals in Lancashire and South Cumbria. The ICB and the trusts are committed to taking action to relieve these pressures, primarily by promoting hospital avoidance, maximising hospital flow and improving discharge, so that patients have access to the right care, in the right place and in a timely way. There are a range of developments in progress at Blackpool Vitoria Hospital and in the community across the Fylde Coast. For example, the final phase of the major refurbishment of the Emergency Village at Blackpool Victoria Hospital is due to be completed in December 2023, which will provide more capacity and improved flow in the Emergency Department. Additionally, there are plans in place to expand virtual wards and maximise their use for both hospital avoidance and discharge over the winter period and by April 2024.
Across the Lancashire and South Cumbria health and care system, NHS England’s 10 high impact interventions to support urgent and emergency care recovery are being prioritised according to local needs and circumstances. For the Fylde Coast, inpatient flow, intermediate care, care transfer hubs and single point of access are the four high impact interventions that have been prioritised locally to also support improvements in hospital avoidance, flow and discharge, alongside the Patient Flow Improvement Programme led by the Trust.
Page 3 From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department. A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.
Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.
As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival. If there is no bed/space for the patient with the speciality team then the patient will remain in ED until a bed becomes available and the speciality team are required to attend ED and visit the patient and complete any required assessments. The learning will also be cascaded across other Trusts. With regards to direct referrals from GPs to the surgical team in Blackpool Victoria going forwards the surgical team have provided re-assurance in all instances that the GP will be advised of the estimated wait times within ED so that this can also be relayed to the patient prior to their arrival at ED.
In respect of the Primary Care element of your concern the ICB Primary Care Team forms part of the SCC arrangements.
As part of these arrangements, Trusts routinely request:
• Situational awareness communications to be sent to General Practices and Primary Care Networks (identified services are under pressure and any referred patients can expect delays)
• Service reminder communications to be sent to General Practices and Primary Care Networks (please use identified services to reduce pressure on other services)
Page 4 These communications are sent via an established newsflash system.
In addition, Trusts routinely request primary care clinical and managerial colleagues to join local ‘pressure response’ arrangements which may also result in the above communications and other actions to mitigate pressures. Again the learning from this tragic case will be shared across Lancashire and South Cumbria Primary Care network for awareness and vigilance in times of sustained pressure.
I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me.
Regulation 28 report - Harold Derek Pedley inquest 17 August 2023
Thank you for your letter dated 1 September 2023 sent following the conclusion of the inquest touching the death of Harold Derek Pedley (known as Derek).
I know that you will share my response with Mr Pedley’s family and I first want to express my sincere condolences to them.
Through the Regulation 28 report you have raised three matters of concern relating to the care Mr Pedley received when he attended Blackpool Victoria Hospital; this letter is in response to these issues and I will respond to each matter raised separately.
Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
AND
Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not
Page 2 being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
As you have recognised and in response to the current pressures facing acute trusts (in this case the Emergency Department), NHS England published a revised Operation Pressures Escalation Levels (OPEL) Framework 2023/24 in August 2023. Lancashire and South Cumbria Integrated Care Board (LSC ICB), through its System Co-ordination Centre (SCC), is currently leading a piece of work to implement this new framework consistently across the LSC system by November 2023. In addition to a new methodology for calculating OPEL levels which will allow for greater differentiation of hospitals under pressure, the new framework mandates a series of “action cards” to be implemented at each of the OPEL levels both by the hospital Trust, and by the wider health and care system. These incorporate a range of prescribed actions aimed at reducing the pressure on the hospital, safely improving flow within the hospital and prioritising patient and staff safety; it will be supplemented by locally agreed actions as we work through the implementation. In addition, the updated SCC guidance for Winter 2023 clarifies the role of the SCC in co-ordinating a response across the full LSC system in order to reduce risk in individual Trusts where there is potential to provide support from other providers within the system i.e. mutual aid.
Linked to the OPEL framework described above, where Blackpool Victoria Hospital is under significant pressure, Blackpool Teaching Hospitals will deploy its Full Capacity Protocol to de- escalate and address overcrowding with the Emergency Department, to spread risk, improve flow and keep patients safe. In such circumstances, and where necessary, a multi-agency approach is deployed in the form of tactical command response where health and care partners come together to agree and implement a range of immediate actions to de-escalate the hospital pressures which, for example, may include: freeing community capacity to enable more timely discharges; running multi-agency discharge events; community healthcare staff in-reaching to the Emergency Department to assess for alternative care pathways to prevent admission; and rapid specialty in-reach to urgent and emergency care pathways, so that patients requiring admission are moved from the Emergency Department.
There are significant pressures across urgent and emergency care pathways at Blackpool Victoria Hospital along with the other hospitals in Lancashire and South Cumbria. The ICB and the trusts are committed to taking action to relieve these pressures, primarily by promoting hospital avoidance, maximising hospital flow and improving discharge, so that patients have access to the right care, in the right place and in a timely way. There are a range of developments in progress at Blackpool Vitoria Hospital and in the community across the Fylde Coast. For example, the final phase of the major refurbishment of the Emergency Village at Blackpool Victoria Hospital is due to be completed in December 2023, which will provide more capacity and improved flow in the Emergency Department. Additionally, there are plans in place to expand virtual wards and maximise their use for both hospital avoidance and discharge over the winter period and by April 2024.
Across the Lancashire and South Cumbria health and care system, NHS England’s 10 high impact interventions to support urgent and emergency care recovery are being prioritised according to local needs and circumstances. For the Fylde Coast, inpatient flow, intermediate care, care transfer hubs and single point of access are the four high impact interventions that have been prioritised locally to also support improvements in hospital avoidance, flow and discharge, alongside the Patient Flow Improvement Programme led by the Trust.
Page 3 From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department. A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.
Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.
As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival. If there is no bed/space for the patient with the speciality team then the patient will remain in ED until a bed becomes available and the speciality team are required to attend ED and visit the patient and complete any required assessments. The learning will also be cascaded across other Trusts. With regards to direct referrals from GPs to the surgical team in Blackpool Victoria going forwards the surgical team have provided re-assurance in all instances that the GP will be advised of the estimated wait times within ED so that this can also be relayed to the patient prior to their arrival at ED.
In respect of the Primary Care element of your concern the ICB Primary Care Team forms part of the SCC arrangements.
As part of these arrangements, Trusts routinely request:
• Situational awareness communications to be sent to General Practices and Primary Care Networks (identified services are under pressure and any referred patients can expect delays)
• Service reminder communications to be sent to General Practices and Primary Care Networks (please use identified services to reduce pressure on other services)
Page 4 These communications are sent via an established newsflash system.
In addition, Trusts routinely request primary care clinical and managerial colleagues to join local ‘pressure response’ arrangements which may also result in the above communications and other actions to mitigate pressures. Again the learning from this tragic case will be shared across Lancashire and South Cumbria Primary Care network for awareness and vigilance in times of sustained pressure.
I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me.