Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Josh Andrew Smith who died on 22 December 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 July 2024 concerning the death of Josh Andrew Smith on 22 December 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Josh’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Josh’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Josh’s family or friends. I realise that responses to Coroner’s Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised concerns over continued delays to ambulance handovers at hospitals and the impact this was having on the speed of ambulance response times.

NHS England recognises the ongoing significant pressure on all NHS services, including ambulances, and continues to prioritise improvements to response times, as well as 4-hour performance in Emergency Departments, to recover and improve urgent and emergency care services. Despite significant challenges, including unprecedented industrial action and higher than anticipated demand, there has been a marked improvement, with over 2.5 million more people completing their A&E treatment within 4 hours in 2023/24 compared to 2022/23.

National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25/09/2024

Response times for Category 2 ambulance calls have improved over the past year, with an average response time over 13 minutes faster compared to the previous year. Other benefits for patients include:

• Tens of thousands more people received the care they needed to return home quickly and safely due to the expansion of same day emergency care (SDEC) services.
• On average, around 500 fewer patients a day had to spend the night in hospital because of a discharge delay, and 13% more patients received a short-term package of health or social care to help them continue their recovery after discharge.
• Urgent community response teams provided 720,000 people with an alternative to going to hospital between April and January 2024.
• Virtual wards have supported more than 240,000 people to get the hospital- level care and monitoring they needed in the comfort of their own home.

The ambitions for 2024/25 have recently been set out in the NHS priorities and operational planning guidance. Relevant to your Report, these are:

• Improve A&E performance with 78% of patients being admitted, transferred, or discharged within 4 hours by March 2025.
• Improve Category 2 ambulance response times relative to 2023/24, to an average of 30 minutes across 2024/25.

NHS England’s operational planning guidance has asked systems to focus on three areas to deliver these ambitions:

1. Maintaining the capacity expansion delivered through 2023/24.
2. Increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, improving flow and length of stay, and clinical outcomes.
3. Continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, admissions avoidance and hospital discharge.

During 2024/25, providers have access to funding of £150 million to support specific local improvement plans for urgent services, including for mental health care. These new improvements will support patients being treated more quickly in A&E or by other services in the community. Up to £150 million will also be available to incentivise the best performing areas and those that improve fastest. The NHS and local authorities will also work together to expand intermediate care services, both in people’s own homes and in community beds, thanks to the additional £400 million Better Care Fund (BCF) available to support further improvements in hospital discharge. There will also be further improvements to, and co-ordination of, community-based services that support people to avoid ambulance call-outs and hospital admissions, by treating people in the most appropriate place for their level of need.

NHS England will also be prioritising:

• Improving the length of stay for all admitted patients (specifically emergency admissions with a length of stay of 1+ day).

• Reducing delays.
• Improving the length of stay in NHS commissioned community beds.

My regional colleagues in the North East & Yorkshire have also engaged with colleagues at the West Yorkshire Integrated Care Board (WYICB) in relation to your concerns, who have advised us of several measures underway to improve flow and ambulance delivery. I understand that WYICB are responding directly to the Coroner, and I refer you to their response for further information on local and system steps.

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 Josh, 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.

Dear Ms Swift,

Thank you for your letter of 15 July 2024 in relation to the Regulation 28 report to prevent future deaths, following the inquest into the death of Josh Andrew Smith. This was issued to:
1. NHS England, Wellington House, 135-155 Waterloo Road, London, SE1 8UG
2. The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT I would like to begin by offering condolences to the family of Josh on behalf of the Yorkshire Ambulance Service (YAS), NHS West Yorkshire Integrated Care Board (WYICB) as the lead commissioner, and our partners across the region. I am sorry for their loss and the circumstances surrounding the death of Josh. I hope this letter provides reassurance of our joint commitment to delivering services that meet the needs of the population within Yorkshire and the Humber, and that the actions we have taken reflect the lessons learnt and the investment and changes made. You have asked for a response from WYICB as the lead commissioner of services from YAS regarding the following areas of identified concern, as well as the actions and timelines that are being taken with our system partners to put in place improvements. My response covers the following:
• Delays in community ambulance responses had improved but continue to remain outside of the target response standards (both on average and at the 90th centile).
• The national target for hospital handover by the ambulance service, of 15 minutes, is still not being achieved. Whilst there has and continues to be efforts made by the ambulance service and acute hospitals to decrease

delays, extended handovers continue to impact upon the speed of the ambulance response to patients waiting within the community.

Background The winter of 2022/23 was a period of extreme pressure across the NHS. Pressure was also evident in the wider healthcare system in Yorkshire and the Humber, with associated difficulties in the timely discharge of patients to the most appropriate care settings. This was due to a number of factors that combined to make a significant impact. During this time, patients and families faced delays in assessment and treatment, and patient flow through acute hospitals was significantly impacted. There were some hospitals that experienced ambulances queuing outside of their Emergency Departments (EDs) due to overcrowding and a lack of beds to move patients to. The pressure was further exacerbated by very high levels of Covid and Influenza infections, coming at the same time as a national spike in Streptococcal infections in children. These widespread infections impacted on all parts of the population, including our staff, and this resulted in high levels of sickness absence throughout all areas of the NHS. As a result, overall ambulance mean response times (December 2022, Category 1) increased to 12 minutes and 58 seconds in the Yorkshire and Humber region, and 10 minutes and 40 seconds in Hull. NHS Recovery Plans In January 2023, NHS England published its Delivery Plan for recovering Urgent and Emergency Care (UEC) services to respond to the challenges we had faced across the country. To support recovery, the plan set out two key ambitions:
• Patients being seen more quickly in EDs: with the ambition to improve to 76% of patients being admitted, transferred or discharged within four hours by March 2024, with further improvement in 2024/25.

• Ambulances getting to patients quicker: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels.

Since April 2023, the three Integrated Care Boards (ICBs) across Yorkshire and Humber have worked jointly through an Executive Leadership Board (ELB) with YAS to agree joint priorities to improve performance and to allocate additional investment. This investment is aimed at recruiting additional ambulance crews, developing new ways of working to avoid conveyance to hospital and investment in new vehicles, all of which are aimed at being able to provide a timelier response and meet increasing demand.

The national target focuses on Category 2 responses, but the overall actions are intended to positively impact on all response category times within Yorkshire and Humber. I am pleased to inform you that because of some of the actions taken within the Yorkshire and Humber region we have seen improvements in response times. In August 2024 the mean Category 2 response time against the national target was 30 minutes and 42 seconds; in Hull the mean Category 2 response time was 27 minutes and 10 seconds, and this reduced to 6 minutes 21 seconds for Category 1. The latter is within the national standards. Hospital Handovers and Ambulance Turnaround Times The correlation between handover delays at Emergency Department and overall ambulance response times is widely acknowledged. Handover times vary amongst our acute trusts in the region, and we seek to ensure the root causes are understood and remedial action is undertaken to improve individual organisations performance. During the calendar month December 2022, the mean ‘handover’ times at Hull Royal Infirmary (HRI) increased to 1 hour, 27 minutes and 50 seconds. The most recent calendar month of reporting (August 2024) showed that the mean ‘handover’ times at HRI had reduced to 33 minutes and 45 seconds. Despite recent improvements, HRI continues to have longer handover times when compared to many other trusts in the Yorkshire and Humber Region, this continues to be a local, system and regional priority with scrutiny and support at all levels to ensure delivery on Trust targets. As part of operational planning for 2024/25, Humber and North Yorkshire ICB has set out an improvement trajectory for HRI to reduce hospital handover times by 3 minutes against 2023/24 baseline with a cap at 50 minutes hospital handover times. Further work continues to support other improvements. In collaboration with the acute trusts, YAS has implemented Quality Improvement initiatives to improve handovers. This helps further reduce the amount of ‘lost ambulance handover time’ and allow ambulances to return to the respond to emergency calls in a timelier manner. In addition, as part of winter planning for 2024/25, NHS England North East and Yorkshire Region are working with each ICB, acute Trusts and YAS to have a specific focus on improving hospital handover times through rapid improvement initiatives. This work will focus on specific plans for each acute Trust with a drive to achieve a national ambition of zero tolerance above 45 minutes. Additional action being taken to improve ambulance response times Implementation of Duty to Rescue protocol – this new clinically led protocol was introduced ahead of the winter period (2023/24) and is now enacted at times of significant operational pressure and has been utilised in Hull. On occasions when there are high number of ambulances in an acute provider waiting to handover patients, the protocol allows for senior clinical decision makers from YAS and our

hospitals to agree to the rapid handover and timely release of an ambulance crew to attend to a specific 999 call, or one who has been waiting to be conveyed to hospital and is deteriorating. The introduction of this protocol has been welcomed by all parties and allows for better management of clinical risk in the system. Alternatives to EDs – more alternative pathways of care are available for use by YAS Ambulance crews or staff within the Emergency Operations Centre (EOC) to safely and appropriately avoid conveyance to hospital. YAS has worked with partners across the urgent and emergency care system to improve availability of these pathways, including through the development of Urgent Community Response (UCR) services. These respond to a patient in their own home within two hours of the call in an aim to meet people’s needs and avoid hospital attendance where appropriate. This also gives direct access pathways to clinicians for Same Day Emergency Care (SDEC) at local hospitals, which allow ambulance crews to bypass EDs for suitable patients and therefore meet people’s needs and improve hospital flow and ambulance turnaround, additional appointments are being made available across Hull and East Riding Practices. An Urgent Treatment Centre (UTC) has been implemented at HRI to stream patients who present with urgent needs and reduce flow into the ED. There is an established ambulance ‘fit to sit’ pathway to avoid ambulance crews having to wait and handover. An Acute Respiratory Hub in place in the East Riding – to support patients with acute respiratory conditions and avoid conveyance to hospital. Established cohorting process in place between YAS and Hull University Teaching Hospitals Trust (HUTH) to release crews back into the community. A programme of work in place to improve flow in HRI, and discharge to support flow from ED to wards. Improvements have already been made to the numbers of patients who have “no criteria to reside”. The EOC have continued to invest in the clinical workforce using clinical navigators to assist in the identification of incidents suitable for an alternative response or which can be clinically assessed and given self-care advice. General Practitioners (GPs) have also been employed to both assist with remote assessment and also to support clinical decision making more generally to improve outcomes and ensure patients are directed to appropriate care relevant to their needs. The EOC continues to improve their referral processes to other services therefore appropriately diverting demand into alternative care pathways. A System Coordination Centre (SCC) has also been developed over the past year. The SCC exists to be a central coordination service to providers of care across the ICB footprint to enable a proactive system response to operational pressures and risks with the aim to support patient access to the safest and best quality of care possible. Governance This Regulation 28 has been discussed at the Yorkshire and Humber YAS Clinical Quality Oversight Group. This is a group of senior clinical leaders of the constituent

organisations sharing matters of concern raised across the Yorkshire and Humber region. This reports to the ELB, noted earlier which has oversight of the Ambulance Service in Yorkshire and includes representatives from YAS and all of the Integrated Care Boards. I chair that Board. This response and the Regulation 28 report and matters of concern will be shared with Hull and East Riding Urgent and Emergency Care Transformation Programme. This oversees the local improvement of ambulance handover and delivery of timely responses in that community. These governance arrangements exist to oversee delivery and operational weekly executive meetings have been established for additional assurance. As an ICB we maintain our shared commitment with both YAS and our partner ICBs within Yorkshire and Humber to ensure we are delivering safe, high-quality services for patients, carers and their families. Thank you for bringing these concerns to my attention. I hope that the detail of the actions we have taken and the ongoing focus on this agenda provides you with assurance that we are working collectively to improve patient safety, and that we continue to make progress to improve response times and to reduce hospital handover times. Finally, I would like to also assure you of our joint commitment to delivering safe services that meet the needs of the population within Yorkshire and the Humber, and that the actions we have taken reflect the lessons learned in this case. If you require any further information, please do not hesitate to contact me.