Linda Green

Dear Coroner Hassell, Re: Regulation 28 Report to Prevent Future Deaths – Linda Green who died on 22nd November 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11th June 2026 concerning the death of Linda Green on 22nd November 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ms Green’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Ms Green’s care have been listened to and reflected upon. Your report raised concerns that there were only six hyperbaric oxygen chambers in the country and none in London, however, information available online is not up to date as to which are operational. You were concerned that all relevant healthcare professionals are not able to easily access information about the location of the nearest operational unit. NHS England commissions six geographically dispersed providers of Hyperbaric Oxygen Therapy (HBOT) services to deliver care to approximately 180 patients per year nationally, in line with the published service specification. The number of commissioned providers is based on modelling to ensure optimal time-to-treatment guidelines are met and that clinicians can maintain competency through providing a minimum number of HBOT treatments per year. The commissioned provider for London and the South East is based in Chichester, and the patient pathway sets out that referrals are directed to the commissioned provider closest to the location of the patient. NHS England acknowledges the Coroner's concern regarding the ability of healthcare professionals to readily identify the nearest operational HBOT service and access appropriate referral routes in time-critical situations. To support timely access to treatment for the most acutely unwell patients, NHS England has developed a national Single Point of Access (SPOA) for the coordination of referrals for patients with suspected gas embolism. The service is expected to become operational imminently. Once implemented, the SPOA will provide healthcare professionals with a single

[Page 2] referral route, enabling referrals to be directed promptly to the most appropriate operational HBOT provider and reducing the need for clinicians to identify and contact individual units independently. Ahead of implementation, NHS England has communicated the forthcoming referral pathway to acute Trust Medical Directors, commissioned HBOT providers and other key stakeholders including Ambulance Trusts, HM Coastguard, and the British Hyperbaric Association. Upon launch, the SPOA contact details will be published on commissioned provider websites and the British Hyperbaric Association website. NHS England will monitor the impact of this process on referral pathways, referral volumes, and access to treatment. NHS England considers that the introduction of the SPOA will provide a clear and consistent national referral route and reduce the risk of uncertainty regarding the location or operational status of individual HBOT units. The contract for the provider at Whipps Cross Hospital ended on 1st October 2025, following which service provision ceased. In line with usual practice when a contract with a provider ends, an exit strategy is agreed with the provider. This included communication of the change in service provision to referring organisations and publication of information regarding service closure and onward referral arrangements. NHS England recognises the importance of ensuring that information relating to operational HBOT services and referral pathways remains accurate and readily accessible to healthcare professionals and will continue to work with providers and relevant stakeholders to support this. In addition to the implementation of SPOA, NHS England has requested that the Intensive Care Society updates and communicates its clinical guidance regarding the management of gas embolism. NHS England notes the Prevention of Future Deaths report addressed to the Royal College of Anaesthetists and the Association of Anaesthetists regarding the establishment and communication of clear referral pathways for this cohort of patients and will seek to work collaboratively with these organisations to support improvements in awareness of referral routes. NHS England will continue to work with commissioned HBOT providers to improve knowledge and awareness of HBOT services and referral pathways amongst key clinical groups, including anaesthetists, critical care staff, neurologists and emergency medicine clinicians, to help ensure that patients requiring urgent HBOT treatment can be referred efficiently to an appropriate operational provider. I would also like to provide further assurances on the 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 Ms Green’s, 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.

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