Derek Weaver

Dear Dr Harris, Inquest touching the death of Derek Weaver am writing on behalf of Guy's and St Thomas' NHS Foundation Trust (the Trust) in response to the Regulation 28 Report to Prevent Future Deaths (PFD Report) dated 16 October 2019 following Mr Weaver's inquest on 3 October 2019. In the PFD Report; you expressed the matter of concern as follows: A consultant thoracic surgeon who was involved in his care after transfer said that he had a higher chance of death because surgery was at a time of SIRS If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages: the first being key-hole surgery, with mortality of only in 100_ That have obviated the necessity of second stage decortication surgery with mortality of 5%, but it was probably needed anyway: The delay in transfer related to a surge in referrals , capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week: There had been pressure to secure greater resources_ The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by the provision of more beds_ The Trust response to the matter of concern Thank you for giving the Trust the opportunity to respond to the concern raised in the PFD Report. The Board and take this issue particularly seriously and am that this issue may have contributed to Mr Weaver's death. Set out below is the context of our Thoracic Surgery Service and the improvements that we have implemented to mitigate any future risk may limiting sorry

The Trust's Thoracic Surgery Unit The Thoracic Surgery Unit at Guy's Hospital is one of the largest in England both by consultant numbers (currently 6) and activity. It currently performs over 1500 cases year, approximately 600 lung cancer resections per annum (representing almost 9% of all cases in England and Wales) and provides advice to other hospitals within large geographical area (South East London, Berkshire, Kent and large part of East Sussex) for patients potentially requiring non-elective and emergency thoracic surgery intervention. significant number of patients (approximately 200 year) are referred as emergencies or for consideration of in-patient transfer; if their clinical condition requires urgent intervention. Pressure on beds , and to a lesser degree_ theatre capacity in relationship to increased activity year 0n year; has meant that it is not uncommon for patients to wait for several to transfer in if are clinically stable. At certain times of the year when influenza and bacterial pneumonias are endemic the number of referrals will often increase and these patients are often septic and unwell: The management of transfers in 2018 At the time of Mr Weaver's death in May 2018 the Thoracic Surgery Service operated "consultant of the day" system. Each day the duty consultant was responsible for reviewing all new referrals and patients already accepted to determine urgency and priority for available beds; The Service required all referral requests to be made by email using the secure NHS mail system so that an electronic record of discussions was available to staff, It was usual practice to advise referrers to update the Unit if there was a clinical deterioration_ At this time the Thoracic Surgery Service also managed their own bed allocation, including beds for elective activity, tertiary referrals and urgent transfers_ The management of transfers in December 2019 In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a "consultant of the week" system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service_ The "consultant of the week" system will be audited to ascertain whether it has improved the management of transfers in_ In October 2019_ to mitigate the risk of capacity issues impacting on transfers, the Directorate Management Team transferred the management of the Thoracic Surgery Service's beds and urgent transfer process to the Site Management Team: This change aligned the Thoracic Surgery Service with other services across the Trust: The process, set out in the UTCI Flow Chart (appendix 1), enables the Thoracic Surgery Service to triage its patients into three categories (1) Admission not urgent;, (2) Urgent Needs admission within 48 hours and (3) Urgent Needs admission immediately and for the appropriate transfer to be arranged. When a patient is identified as 'Urgent Needs admission within 48 hours' , the Adult Urgent TCI Request Form (appendix 2) is completed, sent to the relevant Site Nurse days they May

Practitioner (SNP) Team: The patient's details are then added onto an Excel spreadsheet; which is a live document. Once bed is available, the SNP will contact the patient either at home or via the staff at the relevant healthcare provider to arrange admission and the patient is transferred in_ This process enables the central SNP team to respond to demand appropriately and to have oversight of current waiting lists. If bed pressures increase in Thoracic Surgery Services, the SNP team, which has an overview of all available beds on the s site_ can proactively move suitable patients to alternative beds at Guys' Hospital to facilitate more transfers in to the specialist service The Trust is looking towards an electronic referral system that allows local specialist services to manage their own tertiary referrals and gives the Site Management Team an overview of the current wa list In addition, the Trust Operational Board is currently looking to increase the number of beds on the Guy's Hospital site for Thoracic Surgery patients_ This will be achieved through switching the wards on which services are provided and undertaking the necessary estate works. It is expected that the increased capacity will be available during the first quarter of 2020.