Dear Miss Brown,

Re: Regulation 28 Report to Prevent Future Deaths – Lee Anthony Caruana who died on 6 October 2021

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 June 2022 concerning the death of Lee Anthony Caruana on 6 October 2021. I would like to express my deep condolences to Mr Caruana’s family.

Following the inquest, you raised concerns in your Report regarding the delay in ambulance attendance. You concluded that, from a national perspective, the availability of ambulance crews is being compromised by delays at hospitals, resulting in delays in response times which creates a risk to the life.

For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level. In addition, NHSE set out the next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter, in a letter on 12 August 2022 (Appendix B). This again highlighted the need to target Category 2 response times and ambulance handover delays.

NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support National Medical Director NHS England Wellington House 133 - 155 Waterloo Road London SE1 8UG

14/09/2022

performance and how this can be delivered. Focus remains on improving flow, including maximising alternative pathways to Emergency Departments, and reducing occupancy through the work of the National Discharge Taskforce. Reducing avoidable conveyance ultimately reduces the number of ambulance crews attending Emergency Departments, which in turn will reduce handover delays. Ambulance services have been working closely with their local systems to reduce avoidable conveyance, and to support patients to get the care they need outside of hospital. Current conveyance rates to Emergency Departments are the some of the lowest ever outside periods of national lockdown. Indeed, ambulance conveyance rates have fallen considerably in the last few years (from 59.1% in 2018-19 to 50.0% for July 22). An avoidable conveyance is when a patient, whose health and social care needs could be effectively and safely met in the community, within or close to their own home (or an alternative setting to an emergency department), is conveyed to hospital unnecessarily. I would also like to provide further assurances on the national NHSE 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 Mr Caruana, 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. I note the response from the Birmingham and Solihull Integrated Care Board Chief Executive, and the initiatives being undertaken to improve patient flow within the Urgent and Emergency Care pathways.

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 Miss Brown, Thank you for your letter of 16 June 2022 about the death of Mr Lee Anthony Caruana. I am replying as Minister with responsibility for Health and Secondary Care, and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the.circumstances of Mr Caruana's 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. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE), as well as·the relevant regulator in this case, the Care Quality Commission. The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. Ambulance trusts receive continuous central monitoring and support from the NHSE funded National Ambulance Coordination Centre, and there is a range of support in place to improve performance. NHSE has allocated £150 million of additional system funding for ambulance service pressures in 2022/23, supporting improvements to response times through additional call handler recruitment, retention and other funding pressures. NHSE has also tendered a procurement contract for auxiliary ambulance services with a total value of £30 million. This contract will provide national surge capacity as needed to support the ambulance response during periods of increased pressure by enabling fully equipped and crewed ambulances to be deployed in localities during times of surge pressure. In addition, the Ambulance Auxiliary provider is expected to support the NHS in the event of major incident or other disruptive challenge through the provision of flexible clinical and logistical resource. Further to this, the Department has made significant investments in the ambulance workforce. The number of NHS ambulance and support staff has increased by almost 40% since February 2010, and Health Education England has a mandated target to train 3,000 paramedic graduates nationally per annum from 2021-2024, further increasing the domestic paramedic workforce to meet future demands on the service. In addition, national 999 call handler numbers have been boosted to over 2,300 at the start of May 2022, about 400 more than September 2021, with p·otential for services to increase

capacity further d,uring 2022/23. A £1.3 million national campaign for the 999 call handlers was initiated in March to support trusts. This is alongside a £50 million national investment across NHS 111 in England for 2022/23 to support additional NHS 111 capacity to ensure people get the care they need when they need it and avoid unnecessary demand on ambulances. This builds on additional investment from last year. In July 2021, NHSE allocated an additional £4.4 million to ambulance services to support retention of emergency ambulances and thereby increase the fleet for winter. This improved service capacity, keeping 154 fully equipped vehicles on the road. To further increase ambulance capacity, £20 million of capital funding will be invested in each of the financial years 2022/23, 2023/24 and 2024/25. Additionally, NHSE has undertaken targeted support to some of the hospitals facing the greatest delays in the handover ofpatients from ambulances into the care of hospitals, helping them to identify short and longer term interventions to improve delays and .get ambulances swiftly back out on the road. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support performance and how this can be delivered. Focus remains on improving flow, including maximising alternative pathways to Emergency Department {ED) and reducing occupancy through the work of the National Discharge Taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow. Ambulance services have been working closely with their local systems to reduce avoidable conveyance and support patients to get the care they need outside of hospital; conveyance rates to ED are the lowest ever outside periods of national lockdown. Finally, in 2020/21, £450 million was invested to upgrade A&E facilities in 175 smaller schemes and 25 major schemes. This was used to boost physical capacity in A&Es through expanding waiting areas and increasing the number of treatment cubicles, reducing overcrowding and supporting social distancing throughout the pandemic and helping to clear ambulance queues more quickly. This continued in 2021-22 with investment in 25 major schemes, which so far have delivered 382 waiting spaces, 175 major cubicles, 42 resus cubicles, and 177 SDEC cubicles. To drive further progress and support regional and local system arrangements, the Department has established a national discharge taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow. We will continue exploring options that minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of support. I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Miss Brown

Your Ref: 17372444 - Lee Anthony CARUANA (

I am writing in response to the Regulation 28 issued following completion of the inquest on June 14th 2022, into the sad death of Lee Anthony Caruana on October 6th 2021. I extend my sincere condolences to the Mr Caruana’s family. I note the narrative conclusion of the inquest as ‘Death was due to natural causes contributed to by a delay in ambulance attendance’. I also note your statement ‘in the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life’. The delay in handover of patients from an ambulance into an Emergency Department (ED) is a well described current problem within the NHS. This bottleneck is a symptom of flow along a complex, system-wide pathway, starting with citizens seeking medical help and ending with the timely discharge of patients back home or into a suitable residential location. All system partners have their part to play to ensure flow and efficiency is optimised, whilst safe and effective care is maintained. Flow along this pathway was a problem prior to the COVID-19 pandemic with, for instance, deterioration in metrics of ED performance. However, as we recover from the pandemic this has significantly deteriorated. The causes for this are multifactorial and include, as examples, infection control limitation in space utilisation, workforce reduction through sickness, fatigue and high turn- over, increased demand across all aspects of healthcare and ongoing high bed occupancy throughout all bedded healthcare provision. Birmingham and Solihull (BSOL) are very focused on the major risk posed by delay in ambulance handover to the care of others within the system. A major piece of work was instigated in late 2021, involving all partners, to ensure efficiency of flow within required pathways. This remains a major priority for the newly formed Integrated Care Board (ICB). Before I describe these changes in practice in detail, I will address some of the specifics of this particular case.

I note that Mr Caruana first called 999 at 14:44 on Oct 5th 2021 and a decision to respond was only made nine hours later at 23:53 after several further calls to 111/999 during the afternoon and evening. At this point, the response was classified as a ‘category 2’ but it is stated that ‘due to the pressures on the ambulance service’ an ambulance was not available for just under three hours until 2:42, arriving at 03:10. Records show that Mr Caruana arrived at Queen Elizabeth Hospital at 03:51 and was handed over to medical teams by 03:56 at which point he was critically unwell. Despite all clinical efforts he unfortunately continued to deteriorate and sadly passed away at
05.38. The Root Cause Analysis performed by WMAS and reviewed by Black Country and West Birmingham CCG in their role as host of the regional WMAS commissioning team, identified concerns with call handling leading to delay in decision to respond, in addition to the delay in arrival of an ambulance to convey because of significant operational pressures. As Birmingham and Solihull (BSOL) CCG, and now as an ICB, there has been a refresh of the Urgent and Emergency Care (UEC) programme, commencing in late 2021. This has included a change in governance including two periods of escalation into category 4 incidents with system Gold Command (first due to Omicron December 2021 – March 2022 and then April 2022 – May
2022), system Multi Agency Discharge Events (MADE) events held January 2022 and system UEC quality summits held in March 2022. One of the major priorities of the newly formed ICB is an immediate commitment to production of a system wide Urgent and Emergency Care strategy involving all ICS stakeholders with a current two week multi-stakeholder improvement event to ensure a further step change in delivery. Governance arrangements have been further re-defined for strategic, tactical and operational interventions. This is in addition to an ongoing forensic focus, both within individual organisations and at system level, to ensure that flow through the relevant pathways with joined up, integrated working remains a high priority. This work is described in greater detail below. I hope that this summary of actions across a complex pathway assures you that BSOL ICS and ICB has recognised the importance in driving change to not only reduce the risk held by WMAS with regards to their community response, but to ensure that going forward we have effective and efficient Urgent and Emergency Care delivery for the citizens of BSOL.