Graham Oxley

Dear Mr Fitch Prevention of Future Deaths Report Mr Graham Ian Oxley We are writing to respond formally to your Prevention of Future Deaths (PFD) Report dated 19 March 2026, following the very sad death of Mr Graham Oxley. We are very saddened death, and I am sincerely sorry for the distress and upset this will have caused his family, particularly Mrs Oxley. In your investigation you identified that immunotherapy is being used more frequently, and you raised concerns about the reliable operation of systems intended to support early recognition, escalation, and access to specialist care for patients experiencing serious immunotherapy toxicity. We have reviewed the actions identified in your report and our response is as follows: Access to urgent oncology advice As you heard in evidence, patients receiving immunotherapy receive an alert card which advises them to contact the Weston Park Cancer Centre Assessment Unit triage line. The telephone triage service provides a 24-hour, 7-day-a-week telephone assessment and advice line for patients receiving cancer treatment under the care of Weston Park Cancer Centre. Its purpose is to ensure timely, safe, and evidence-based assessment of symptoms related to cancer and its treatments, and to direct patients to the most appropriate care setting. The phone line is staffed as follows:
- 07:00-19:30 - At least 2 nurses; where possible, this role is rotated between a number of staff members over the period of the shift to minimise fatigue.
- 09:00-13:00 - An additional nurse supports the triage line to reduce morning call wait times.
- 19:00-07:30 - One Band 6 nurse. The nurses who staff the triage line are all experienced cancer nurses who have completed the UK Oncology Nursing Society (UKONS) Systemic Anti-Cancer Therapy competency package, which is a national, standardised framework for training and assessing nurses and practitioners handling, administering, and educating patients on Systemic Anti-Cancer Therapy (SACT).

PROUD TO MAKEADIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST Staff answering the calls use the UKONS triage tool to assess patients symptoms and identify risks; this assessment supports staff to advise on appropriate action which may include:
- Referral to A&E for clinically very urgent cases
- Urgent attendance at the Weston Park Assessment Unit for medical assessment
- Booking for attendance at a rapid assessment outpatient clinic. , we recognised that there was an increasing number of calls being received by the triage line. On review it became apparent that patients were using the triage line number because they either did not have the correct phone number or were unable to get a response on the alternative number provided. These calls led to increased waiting times for patients needing to access specialist advice and support. In response, we have reviewed and redesigned how patients and service users contact Weston Park Cancer Centre. We have reduced the amount of contact numbers in circulation and put in place arrangements to ensure the numbers that are publicised are answered by the right team who can assist with the query. As part of this change, patients contacting the triage line are presented with three options: Option 1: Urgent medical advice Option 2: Appointments (including Radiotherapy and Chemotherapy) Option 3: Transport and Secretarial Teams This aims to ensure that patients not requiring the specialist support offered by the triage line are re-directed to a more appropriate team. This process was introduced in April 2026 and the team supporting this change are meeting weekly to review performance and address any issues following the go-live date. In response to your report, we have further reviewed the arrangements for the triage line and have identified that patients may still wait some time for their call to be answered. We have put in place call-handling escalation arrangements whereby if call wait times exceed 12 minutes, staff on the triage line escalate immediately to the inpatient matron, who will take action to arrange further cover. Where patients wait over 12 minutes, staff will incident report this, creating a clear record of any instances where the escalation process is enacted. This escalation process was introduced in early May, and we plan to audit the impact of these changes in three time. Immunotherapy alert card pathway As detailed above significant action has been taken to ensure that patients are able to access specialist advice via the telephone triage line and be provided with appropriate care. However, we acknowledge that there may be times that patients, such as Mr Oxley, present at our Accident and Emergency (A&E) Department. As I am sure you are aware there is significant pressure on A&E Departments and therefore all patients are triaged to ensure that the most clinically urgent are prioriti reviewed regularly to ensure that any change in presentation is identified, and care can be escalated as appropriate. We are aware of the risk presented by long waits experienced by patients in A&E and there is Trust wide work championed by me, as Chief Executive Officer, alongside the Chief Operating Officer to address challenges including the increased use of patient streaming to ensure patients are seen in the most appropriate locations, whilst reducing pressure on A&E, and real-time reviews of delays to inform collaborative pathway improvements. The department has a comprehensive plan aimed at reducing waiting times to see a clinician

PROUD TO MAKEADIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST and we have work underway to reduce the time patients wait for admission and overall time spent in the department. In Mr increased risk and as such he was placed appropriately in a side room. There is a clear process following medical review in A&E for patients to receive a specialist oncology review which would, where appropriate, lead to an admission to Weston Park Cancer Centre. In response to your concerns, we will review this pathway and consider if any changes are required. In addition, as you have acknowledged, cancer therapy is rapidly expanding and changing field and the oncology team is therefore providing update teaching to the entire trust, including people who work in acute and emergency care focusing on a variety of topics including immunotherapy toxicity, and rare complications of treatment such as MMM (Myocarditis, Myositis, and Myasthenia Gravis) as occurred in Mr Oxley's case. Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have viewed this matter. We are absolutely committed to learning from death and implementing these actions. Furthermore, we intend Inquest to present the actions set out in this letter and to give the family the opportunity to raise any outstanding concerns not addressed at the Inquest. Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification.