Dear Mrs Wood,

Thank you for your letter of 8 January 2023 to Steve Barclay as Secretary of State for Health and Social Care about the death of Kyriacos Athanasis. I am replying as Minister with responsibility for Health and Secondary Care. Please accept my sincere apologies for the delay in responding to this matter.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Athanasis’ death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns about ambulance handover delays, emergency department capacity, patient safety checks, and patient discharge at James Paget University Hospitals NHS Foundation Trust (JPUH). In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. My officials advise me that the Integrated Care Board (ICB) responsible for JPUH, Norfolk and Waveney ICB, provided a comprehensive response on 3 February 2023 which included information on the improvements being made locally, and details of a serious incident investigation report following Mr Athanasis’ death.

I recognise the significant pressure the NHS has been under since the pandemic. That is why we published our Delivery Plan for Recovering Urgent and Emergency Care Services. The plan aims to deliver one of the fastest and longest sustained improvements in emergency care waiting times in the NHS's history. It sets out an ambition to improve A&E wait times to 76% of patients being admitted, transferred, or discharged within four hours and to reduce average Category 2 response times to 30 minutes this year, with further improvements to be set as part of the NHS planning guidance for next year 2024-25.

We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6

new ambulance hubs and 42 new and upgraded discharge lounges in hospitals across the country, backed by nearly £50 million investment. The ambulance hubs will help reduce handover delays and get ambulance back on the road faster, while the discharge lounges will speed up the safe and effective discharge of patients from hospital, freeing up hospital beds.

A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years in being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.

In addition, Same Day Emergency Care (SDEC) services will be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients receiving SDEC can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.

We recognise there is variation in performance across the country. That is why the delivery plan also provides for a new tiering performance and improvement approach to provide targeted support to challenged systems. There is support in place at national and regional level to support Tiers 1 and 2 with a universal improvement support offer being made available for all systems which will help improve system performance across the whole patient pathway.

At a national level, we have seen significant improvements in performance this year compared to last year. Average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were almost 47 minutes faster in December 2023 than the same month last year, a 51% reduction. Average East of England Ambulance Service NHS Trust Category 2 response times decreased by 60% over the same period.

Further, national data shows that 69.4% of patients were admitted, transferred, or discharged within 4 hours of arrival at A&E, compared to 65.2% the same month last year, while performance at JPUH was 66.5% in December 2023, an improvement of 4.4% over the same time period.

I hope this response is helpful. Thank you for bringing these important issues to my attention.    

Yours,

HELEN WHATELY

03 February 2023

PRIVATE & CONFIDENTIAL

County Hall Martineau Lane Norwich NR1 2DH

Direct Tel: 01603 595857 Web: https://www.improvinglivesnw.org.uk/ Email: nwicb.contactus@nhs.net

To Catherine Wood, Assistant Coroner for the Norfolk Area

Re: Prevention of Future Deaths Report for Mr Kyriacos Athanasis

We are writing in response to the publication of a Prevention of Future Deaths Report (ref. 2023-
007) dated 06/01/2023 in relation to the death of Mr Kyriacos Athanasis at the James Paget University Hospital (JPUH) in Gorleston, Suffolk. As the NHS Integrated Care Board for Norfolk and the Waveney area of Suffolk, we commission care from JPUH and the urgent and emergency care system that it sits within.

This response provides context, addresses the concerns raised in your report and sets out a timeline of actions. We hope that the below is helpful, and we would wish to reassure you, and the family that in providing this response we have not lost sight of the suffering that has resulted from Mr Athanasis’ death and its impact on his family and the staff caring for him at the time.

Case Background Mr Kyriacos Athanasis was an 88-year-old man who had a past medical history of asthma, chronic kidney disease stage 3, hypertension, orthostatic hypotension, type 2 diabetes mellitus and ulcerative colitis. At the beginning of 2022 he was becoming frailer and suffered from multiple falls, several of which led to admissions for hospital care and treatment. A discharge summary from March 2022 summarised a diagnosis of multifactorial falls, including neuropathy (loss of sensation to the lower limbs), reduced vision, frailty due to old age, some cognitive (thinking) impairment and chest infection. Mr Athanasis had a fall at home, at some point on 16th May
2022. There was an extremely long wait for an ambulance to attend, by which time, Mr Athanasis was on his feet and mobilising. However, he was subsequently able to communicate that he was experiencing a significant amount of pain and he was taken to the JPUH arriving at around 21.30 on 17th May 2022. Mr Athanasis experienced a delayed handover into the hospital Emergency Department (ED), where it was found that he had an unstable cervical fracture.

Mr Athanasis died from a multifactorial pneumonia, predominately due to the consequences of his fall on a background of frailty and type 2 diabetes mellitus, with the inquest finding the short form conclusion of accidental death.

General Background In January 2022 a system-level Gold Command Group comprising of chief executives and senior clinical and operational leads from provider organisations was established and facilitated by our organisation, which was a Clinical Commissioning Group at the time, to develop a plan for ‘in extremis’ actions to respond to system resilience incidents following increased operational

pressures over Winter 2021-2022. As a system, we continued to experience the following ‘symptoms’ of significant, sustained pressure across 2022, including:

• Increasing hospital occupancy. High levels of occupancy continued to be sustained across the system leaving very little room for decompression actions. COVID-19 and seasonal illness continued to impact on bed management and staffing levels across health and social care providers.

• Increasing length of stay and ‘no criteria to reside’. Patients were having longer admissions and remaining in beds with no criteria to reside; having no medical need to stay in hospital. This impacted on flow through the hospitals and the wider system, as well as deconditioning and the ability to meet patient needs in non-standard ward settings.

• Increasing ambulance handover delays. Poor flow through the system impacted on the timeliness of ambulance handover into hospital Emergency Departments (ED) and prolonged care of patients in waiting ambulances. This issue was highlighted during the inquest of Mr Athanasis.

• Worsening ambulance response times. Long handover delays resulted in ambulance crews waiting outside ED, which led to longer response times in the community, including for the most urgent life threatening and life altering calls. Again, this wider issue was highlighted during the inquest of Mr Athanasis.

We are mindful that the challenges described above also reflect a national picture and that we are not alone as a system in responding to these significant and sustained pressures. Our response to the concerns raised in your report set out how the ICB has worked with providers, within our local remit and resource, to collectively address and mitigate the risk of adverse incidences impacting on our patients and staff, and to:

• Reduce ambulance handover delays and improve community response times.
• Support clinical decision making and improve access to pre-hospital pathways of care.
• Improve discharge and patient flow across the system.
• Support the social care market to ensure it is sustainable and meets population needs.

Concerns Raised by the Coroner

We understand that the concerns of the Coroner are as follows:

1. A delay in the transfer of Mr Athanasis from the ambulance due to a lack of space within the ED.

2. Due to the known delays in transferring patients into the ED, senior clinicians were undertaking safety checks of those patients left in ambulances to assess urgency and need for a trolley or a bed.

3. The mechanism for undertaking this patient check was not sufficient in this instance, resulting in a delay in diagnosis.

4. That ED overcrowding is a frequent occurrence and is a consequence of an inability to discharge patients back into the community.

5. That the ED continues to operate over capacity resulting in delays in treatment and diagnosis.

Response to Concerns 1, 2 and 3 In summary, we understand that these concerns relate to the delayed handover from the ambulance into the Emergency Department (ED), missed opportunities to safety-net the patient and delay in diagnosis and treatment.

ICB actions taken to improve ambulance handover times and reduce delays in diagnosis and treatment:

The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition. This is an exceptional intervention that can only be mobilised in specific clinical circumstances. This initiative was mobilised across all 3 Acute Hospitals in Norfolk and Waveney in mid-late May 2022.

Additionally, in order to effect earlier release of ambulance resources into the community, additional ambulance resources have been utilised across all three Acute Trusts to enable cohorting of suitable patients, thereby releasing ambulance resources. Whilst this does not address directly, ambulance handover times it does improve the safety of patients within the community who would otherwise face longer waits for ambulance attendance. This is supported by established frameworks which identify the scope of clinical practice of the available hospital staff members and is further supported by provider and system level escalation frameworks such as the OPEL and critical incident management framework.

Since May 2022 the ICB has supported all 3 acute hospitals within our system, including the JPUH, to further develop and expand its GP Streaming Unit which provides a pathway for ED staff to assess patient needs on arrival and ensure that those who are more suitable for GP care can attend the unit co-located within the department. This helps to create flow and promote more prompt clinical assessment.

ICB actions taken to support providers to safety-net patients in the event of a delay in handover to ED:

The ICB coordinated systemwide adoption in October 2022 of the Professional Standards of Care for Patients Waiting in Ambulances to ensure patients awaiting handover to ED receive consistent, timely and clinically appropriate care, and that processes are in place to rapidly identify and escalate care needs for deteriorating patients. The ICB continues to monitor compliance with these standards, through daily system calls and discussion with site teams, as well as focussed on-site quality visits.

In addition to the above, the ICB has continued to support provider-level actions to increase oversight of patients in waiting ambulances, enabling collaboration between ambulance and hospital providers to put in place new ways of working to maintain patient safety, that transcend traditional organisational responsibilities. For example, this includes a ‘pit-stop’ assessment model that came into effect at JPUH in June 2022, which enables early diagnostics to be commenced for patients before they enter the ED. This initiative was supported by the use of additional temporary staff including the use of reservists, additional bank staff and medical

students as assist in the more timely handover of patients into the ED where clinically appropriate.

Wider ICB actions taken to avoid unnecessary ambulance conveyances, and ensure that community services are utilised to manage activity and demand more effectively:

The ICB has focussed resources into the expansion of Same Day Emergency Care (SDEC) provision across all acute hospital sites as an alternative to ED attendance. This is an additional service which provides an alternative pathway for patients who require diagnostics and assessment, which can be undertaken without an overnight stay or prolonged hospital attendance.

The ICB continues to commission our integrated urgent care provider to deliver a 24-hour Clinical Assessment Service (CAS) run by GPs and Advanced Practitioners. The CAS undertakes revalidation of 999 calls for EEAST to help avoid unnecessary ambulance conveyances as well as delivering a direct Healthcare Professional Advice line which provides senior clinical advice, including ‘Call Before You Convey’ decision-making support for ambulance staff while they are on-scene. This work has been developing over time, with the ICB supporting a review and refinement of these services to meet presenting pressures e.g., reduction of the Healthcare Professional Advice line response standard from 30min to 10min.

Additionally, the ICB has worked closely with our integrated urgent care provider to implement a virtual ‘Open Room’, which started as a trial in April 2022, to enable senior clinical staff in the community to ‘pull’ appropriate patients out of the 999-call queue and divert them to more appropriate alternative pathways to meet their needs. This could include interventions and services such as therapy assessments, urgent community support, medication review and community falls response. This became a substantive service from August 2022 following positive evaluation by the ICB.

The ICB continues to commission the East of England Ambulance Service Trust to provide the Norfolk and Waveney Mental Health Joint Response Car (MHJRC) which enables a paramedic and mental health practitioner to triage people within their home environment, and plan follow up care, instead of an ambulance conveyance to hospital for the purposes of accessing mental health care provision, where safe and appropriate.

Response to Concerns 4 and 5 In summary, we understand that this concern relates to the reduced discharge profile, hospital congestion, the ongoing impact on ED capacity and ambulance release and the risk of harm to patients waiting for an ambulance as well as patients whose diagnosis and treatment is delayed at ED.

In Norfolk and Waveney, a focus on the discharge pathways for Pathway 1, 2 and 3 patients were identified as the most impactful operational action:

• Pathway 0 patients who can return home without any health or social care support.
• Pathway 1 patients who need a package of care in their own homes.
• Pathway 2 patients requiring a recovery package, rehab or reablement in a bed.
• Pathway 3 patients requiring a specialist bed or long-term placement.

Nationally, the NHS stopped the Hospital Discharge Fund on 31 March 2022, which had essentially funded 4 weeks of ‘free care’ to support patient discharge, regardless of who was responsible for commissioning this care and which also paid for a large range of services and beds. This meant that on 1st April the Norfolk and Waveney system lost funding for

approximately the equivalent of 161 beds in the health and social care sector. NHS Norfolk and Waveney ICB took a local decision to create a 3-month transition fund to support this work, utilising our reserve budget. However, on 01 June 2022 this local funding extension ceased, in line with the national mandate to stop funded ‘free care’.

However, since August 2022 the NHS has released additional money for investment in discharge resources. In the first allocation the Norfolk and Waveney system was awarded £9m revenue and £2m capital, which was invested in new health and social care beds and community packages of care creating the equivalent of approximately 250 beds. In mid-November 2022 the government announced a further £500m fund for health and social care, of which our system share was approximately £11m which is currently being used to commission additional care and support services to further ease the burden on hospital beds. A third award was announced in January 2023 providing a further £3.74m revenue to be spent by 31st March 2023. The ICB is coordinating the system Discharge Programme which brings providers together to collaborate on the utilisation of this money; jointly planning, delivering, and monitoring improvement actions, including:

• Executive-level focus on length of stay and discharge and Discharge Board;
• Use of an incident management framework to respond to operational pressures robustly;
• Deep dives into all pathways and the opening of additional beds;
• Additional focus on supporting hospitals with Pathway 0 discharges;
• Participating in regional ‘deconditioning games’, and patient reconditioning initiatives;
• 10 new initiatives to improve hospital flow and discharge in the Acute Hospital setting;
• 10 new initiatives to improve hospital flow and discharge in the Community setting;
• 10 new initiatives to improve flow and discharge in Mental Health Services;
• Increasing hospital discharges before 12 noon;
• Improving accessibility of hospital transport to facilitate timely discharge;
• Bringing in other agencies to support Domiciliary Care in people’s homes;
• Bringing in new agencies to provide additional health and social care staffing;
• Active engagement with Voluntary, Community and Social Enterprise sector.

The ICB has also placed senior clinical staff in to our three Acute Hospitals for focussed periods of on-site support, to support the management of escalations in a timely manner. Not only does this provide additional operational support to frontline colleagues, utilising ICB staff experience, it also improves ICB oversight and assurance, enabling the ICB to actively reflect on the operational impact that their system-level interventions (as described above) are having on patients and the staff delivering their care. The Norfolk and Waveney ‘Leading for System Change’ project launched in 2022, bringing together key colleagues involved in discharge across the Integrated Care System (ICS) with a focussed remit to understand, mitigate and rectify some of our underlying problems as a system which include:

• Access to timely assessments (e.g., therapy needs, Continuing Healthcare, Care Act).
• Digital solutions to improve communication and workflow.
• Improving system intelligence around ‘demand’ and resource management.
• Workforce support and ‘culture’ of reablement.

The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and reablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital

capacity and more generally, across the Norfolk and Waveney care sector. The ICB has also commissioned additional domiciliary care, put in place in partnership with the local authorities. The resilience and capacity of our health and social care workforce is escalated regularly to our NHSE Regional Team, for support and we continue to work closely with Norfolk County Council and Suffolk County Council to support the local social care provider market.

ICB Oversight of Serious Incident and Learning The James Paget University Hospital undertook a serious incident investigation at the time of Mr Athanasis’ death, in line with NHS national policy and the learning was shared with NHS Norfolk and Waveney ICB (at that time, NHS Norfolk and Waveney Clinical Commissioning Group). The hospital investigation identified learning points around the management of cervical spine injuries in the elderly and the challenges of neck immobilisation, versus respiratory distress. An action plan for improvements has been shared internally and with NHS Norfolk and Waveney ICB. In summary, progress with the identified actions is as follows:

Action 1: Hospital to provide dedicated educational sessions to their Trauma & Orthopaedics junior/senior doctors and consultant surgeons and ED staff, on the management of cervical trauma in the elderly, including the challenges of immobilisation. Progress: Trauma training in place.

Action 2: Hospital to undertake a review of their spinal referral process and develop a new Standard Operating Procedure to supplement their existing clinical guidelines. Progress: Action to be completed by the end of March 2023. ICB will monitor and provide any support required.

Action 3: Hospital to share the learning from this case at their Medical and Surgical Clinical Governance Meetings. Progress: Itemised for 24 March 2023. ICB will monitor and provide any support required.

Action 4: Hospital to source Aspen® Collars for their Emergency Department. Progress: Action complete.

NHS Norfolk and Waveney ICB continue to work closely with NHS Suffolk and North East Essex ICB, which is the regional lead commissioning body for the East of England Ambulance Service Trust (EEAST) to ensure there is a common approach between healthcare providers and the local ambulance service to learning and preventing future adverse incidents, including those arising from ambulance handover delays, across the EEAST footprint and the Hospitals across the region so that there is parity and consistency.

In March 2022, NHS Norfolk and Waveney ICB became an early implementer locality for a new regional framework , developed by Suffolk and North East Essex and EEAST, which has been rolled out to each ICB in the region (Bedfordshire, Luton and Milton Keynes; Cambridgeshire and Peterborough; Hertfordshire and West Essex, Mid and South Essex, Norfolk and Waveney and Suffolk and North East Essex), EEAST and the hospitals within their footprint. The framework provides a consistent approach to system level learning in response to urgent and emergency care treatment delays. In Norfolk and Waveney this is delivered by the System UEC SI Tactical Group, which brings together Norfolk and Waveney providers to share and review themes, identify learning and, where appropriate, make shared recommendations, in addition to their internal organisational learning. These recommendations are then fed into the Norfolk and Waveney system resilience and transformation plans, as well as broader quality improvement work around patient flow, including pre-Hospital community-based interventions and discharge to assess.

Ongoing ICB Monitoring and Escalation As an area, we currently continue to experience capacity pressures, alongside many other areas

nationally. We continue to follow the national NHS Operational Pressure Escalation Level Framework to identify, escalate and respond to flow pressures across our system. The ICB continues to coordinate a programme of local improvement, which is built optimising and utilising the funding we have been allocated, to focus on the following local priorities:

• Alternatives to ambulance conveyance;
• Falls response;
• ED surge measures;
• Care Home support;
• System incident management;
• Workforce;
• Discharge.

Following the abolition of CCGs and the creation of Integrated Care Boards in July 2022, our organisation is now a Category 1 Responder under the Civil Contingencies Act 2004. This builds on the ‘oversight’ role of commissioners, extending its responsibilities to coordinate the activities of the wider health system to support critical and major incidents including sustained surge pressures. This is achieved by:

• System-level grip and control of operational activity across the ICS and system level operational reporting;

• Providing a platform for ICS organisations to collaborate and manage variations in patient flow and operational delivery and remove barriers to collaboration;

• Agree short term operational work that needs to happen at ICS level and link to medium to longer term Transformation Plans.

• Provide system challenge / support to maintain delivery of ICS operational activity and flow;

• Agree key ICS operational risks and monitor delivery / impact of mitigation actions and escalate to ICS Executive Management Team where necessary.

• Coordinate expenditure of regionally and nationally allocated short term / seasonal funding for our area, and ICS urgent and emergency care response to significant and major incidents.

Formalisation of these responsibilities provides the ICB with a much more clearly defined role to coordinate the system’s response to demand and capacity pressures, as described within this response. It provides operational ‘grip’ on emerging risk that is required to keep the system as safe as possible while improvement and transformation actions embed.

Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:

• Development of a virtual ward across our three Acute Hospital sites to support early discharge, enabling patients to receive the same high level of investigation, management, treatment, and care from the comfort of their own homes, thereby diverting

those who might otherwise attend the ED.

• Development of an urgent community response service offering an alternative to meet the needs of individuals, rather than requiring an ambulance response and/or attendance at the ED.

• Development of Urgent Treatment Centres as an alternative to ED attendance where clinically appropriate.

Conclusion We hope that the above is helpful. The Norfolk and Waveney system continues to respond to the pressures and challenges described in this response, in a way that shares accountability and responsibility for mitigating actions across the system. Ambulance handover is a theme that the system has collectively prioritised, and learning from adverse incidents has informed the quality improvement and patient safety initiatives described above.

Our thoughts are with the family as they come to terms with their loss.

If you require any further information relating to this response, please contact:

Executive Director of Nursing NHS Norfolk and Waveney Integrated Care Board