Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Jade Griffiths-Jones who died on 4 June 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 2024 concerning the death of Jade Marie Griffiths-Jones on 4 June 2023. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Jade’s family and loved ones. NHS England would like to assure the family and the coroner that the concerns raised about Jade’s care have been taken into account and reflected upon. 

The report raised concerns around the demands on West Midland Ambulance Service and hospital handover delays and how ambulance response times have been impacted by this. NHS England recognises the significant pressure on ambulance services since the COVID-19 pandemic. Ambulance services have seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.

The plan outlined key actions to recover and improve urgent and emergency care services, including:
• improving ambulance response times;
• increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms);
• alongside broader system actions to improve flow through hospitals and reducing handover delays;
• speeding up discharges from hospitals;
• expanding new services in the community.

These key actions should help ambulance crews to get back on the road to the next waiting patient more rapidly.

We understand ambulance response times have not returned to pre-pandemic levels, however, there have been improvements in ambulance response time targets nationally during 2023/24. The 2023/24 year-end Category 2 mean was 36 minutes National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 31 May 2024

23 seconds which is 13 minutes 37 seconds lower than 2022/23. For 2024/25, the Delivery Plan continues to focus on the improvement of ambulance Category 2 response times. Ambulance services are expected to maintain the increases in capacity achieved throughout 2023/24, alongside the continued development of alternative referral pathways (e.g. urgent community response) to ensure that patients receive timely and high-quality care.

Handover delays have reduced nationally over 2023/24 but still show a significant issue to achieving increases in ambulance service capacity, particularly within certain geographical areas. Targeted handover improvement work (for the acute trusts with the highest amount of handover delays) has been undertaken throughout 2023/24. Hospitals have worked collaboratively with ambulance services and the NHS England Regional teams to ensure patients are able to be handed over as quickly as possible. This includes utilising Fit 2 Sit for patients who can safely sit on a chair (rather than a hospital trolley), and direct referrals to Same Day Emergency Care and Urgent Treatment Centres. Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.

Within the Midlands region, the ambulance contract oversight is managed via a joint commissioning model, with regular system review meetings held by Derbyshire (East Midlands Ambulance Service) and Black Country (West Midlands Ambulance Service), and NHS England Midlands region. The system review meeting explores service delivery, concentrating upon the support needed to improve efficiencies, response standards, quality of care and the improvements needed to address the Care Quality Commission’s (CQC) Regulation 12 for Safe care and treatment. It is recognised through the joint commissioning model, and by East and West Midlands ambulance services that operational productivity has fallen (post pandemic). Both West Midlands and East Midlands have improved the position greatly throughout 2023/24, but also recognise that there is further work to be done. I would also like to provide assurance that the Midlands Regional Director has been sighted on and reviewed your report and response.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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 Brown,

Thank you for your letter of 17 April 2024 to the Secretary of State for Health and Social Care , about the death of Jade Marie Griffiths-Jones. I am replying as Minister with responsibility for urgent and emergency care.

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mrs Griffiths- Jones’ death and I offer my sincere condolences to her family and loved ones. It is vital that where Regulation 28 reports raise matters of concern these are looked at carefully so that NHS care can be improved. I am grateful to you for bringing these matters to my attention.

Your report raised concerns about ambulance response times at the West Midlands Ambulance Service (WMAS) University NHS Foundation Trust, and the hospital handover delays that they experience. You have appropriately shared your report and concerns with NHS England and Birmingham Integrated Care Board who are best placed to respond on the specific action being taken locally to improve ambulance response and handover times. You also shared your report with the Care Quality Commission who I note inspected WMAS in February 2024 and, while rating the trust good overall, raised the need to improve response times.

As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the NHS is facing and the impact of waiting times for patients. In January 2023, NHS England published a two-year ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times with targets for this year for a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average. An update to this plan has now been published, to build on learnings from the first year and to continue to support systems to improve performance and reduce waiting times. The plan is available at: NHS England » Urgent and emergency care recovery plan year 2: building on learning from 2023/24

Your report highlights that WMAS were under high demand at the time of the incident. A primary aim of the Delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.

2 This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.

I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.

At a national level, we have seen improvements in performance. Since January 2023, national average A&E 4-hour performance has improved from 70.8% in 2022/23 to 72.1% in 2023/24. In 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%. WMAS average Category 2 response times were over 12 minutes faster in 2023-24 compared to the previous year, a 25% reduction.

Thank you once again for bringing these concerns to my attention.

Yours,

Dear Miss Brown

Inquest Relating to the Death of Mrs Griffiths-Jones on 04/06/23 - Response to Regulation 28 Report to Prevent Future Deaths

I write in response to the Regulation 28 Report made by you following the inquest into the death of Mrs Griffiths-Jones.

Firstly, on behalf of NHS Birmingham and Solihull, we extend our sincere condolences to the family and friends of Mrs Griffiths-Jones.

NHS Birmingham and Solihull (BSOL ICB) has carefully considered the concerns raised within your report to prevent future deaths, specifically relating to your concern that:

• Death was due to natural causes in combination with a delay in ambulance attendance arising from increased demand for ambulances and significant hospital delays.

• Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.

• The availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.

All partners acknowledge the risk posed for citizens awaiting an ambulance response for longer than deemed safe within a community setting. As you outline, this can be caused by various factors including an increase in demand, the number of crews on duty within the ambulance trust and the productivity of these crews. This latter factor is influenced by how much time the crews spend outside of hospitals awaiting handover of their patient, although other factors also contribute. It is also acknowledged that, although there are significant mitigations in place to prevent harm for those cared for in the back of an ambulance on a hospital site, remaining in the back of an ambulance at a hospital site is not without clinical risk, and is also a poor experience of care for the individual affected.

This letter summarises the way that partners across NHS BSOL are working together to reduce delays in handover at hospitals and thus to reduce any potential harm to those awaiting an ambulance response within our community.

It should be noted that the current performance metric specified by NHS England is that category 2 response times should be an average of 30 minutes and this has been included in our 2024/25 operational plan for the NHS locally and by West Midlands Ambulance Service (WMAS). The average monthly category 2 response time for BSOL across 2023/24 was 37 minutes and 56 seconds which is above the national standard of 30 minutes. This has continued to improve over the last few months as illustrated in the graph below.

On a day-to-day operational level, partners within BSOL providing emergency care, work closely with colleagues at WMAS to ensure that care provided as a whole emergency partnership is as safe as possible. The BSOL System Co-ordination Centre (SCC) co-ordinates interactions with a ‘battle rhythm’ of partner meetings, but individual partners, especially University Hospital Birmingham NHS Trust (UHB) and WMAS colleagues are in frequent and regular contact to enable best working together. Although at times all parties can be managing significant risks within their own provider footprint, there is a well-developed understanding of the concept of risk equalisation, where one provider will need to take on extra risk associated with a greater risk within another provider. The number and length of category 2 waits are a well understood marker of such community risk with professional and respectful co-operation to reduce wherever possible.

Measures to reduce ambulance handover delays are multifaceted and are distributed across the patient pathway. They fall into the categories described below:

• Reducing health care demand by enabling self-care.

• Provision of effective alternatives for public access to prevent Emergency Department (ED) attendance with signposting.

• Provision of effective alternatives for health care professional access to prevent ED attendance.

• Effective management within UHB to reduce ED overcrowding.

• Prompt and effective discharge processes from all providers to final destination. In addition, measures for the ICS to implement are summarised within NHS England » Delivery plan for recovering urgent and emergency care services.

Each provider oversees the pathways that they deliver within their own governance frameworks. However, to function effectively the urgent and emergency care pathways have to work as a whole system. Changes in capacity in any part of this complex programme can have effects elsewhere, and as discussed, there are occasions where risk sharing has to occur to ensure that the risk of harm is equalised, where possible, across all pathways.

For this reason, oversight is via a UEC Delivery and Improvement Board which is chaired by the ICB Chief Delivery Officer with senior representation from all system partners. This Board provides integrated system leadership to set and deliver the Urgent and Emergency Care Strategy, with a focus on equity of access and system efficiency.

Where provider performance metrics are a cause for concern these are reviewed weekly within the ICB System Oversight Group, along with appropriate change programmes with trajectories for improvement. Quality concerns associated with UEC pathways are again reviewed via individual provider governance arrangements with ICB agreed metrics. These are discussed monthly within an escalation pathway to the System Quality Group and Quality Committee, where all long ambulance waits and excessive ED stays are discussed and escalated to the ICB Board along with mitigations to prevent harm and improvement plans. Operationally, individual providers have in place a daily rhythm that oversees the efficient, effective and safe delivery of care within their provision. This continues into out-of-hours with senior managerial input. The ICB hosts the SCC, which holds full accreditation status from NHS England in compliance with the national SCC specification. The team are responsible for co-ordinating the system-wide response to pressure points, such as ambulance handovers and increases of activity in EDs, and supporting interventions in all pathways. They have access to a wide range of data to enable their role and bring system partners together throughout the day, and into the out-of-hours period, to ensure joined up problem solving, effective flow and maintenance of safety.

WMAS is not directly commissioned by BSOL, but by the Black Country ICB on behalf of the West Midlands ICBs, with BSOL as associate commissioners. As such BSOL contributes to discussion on performance and quality via established routes with Black Country colleagues. Operationally, however, WMAS colleagues are very integrated into BSOL provision and daily oversight rhythm. This not only includes the paramedic crews themselves, but presence of a senior co-ordinating role, the Hospital Ambulance Liaison Officer (HALO), and until recently provision within UHB with Ambulance Decision Areas (as below). The overall objective of the HALO service is to facilitate the handover of patients presenting at ED by ambulance, in a clinically safe, effective and efficient manner, thus enabling crews to turnaround ambulances in readiness to respond to other emergency calls. This provision reduces the build-up of ambulance downtime at ED sites.

Senior operational colleagues are also involved in SCC calls to ensure that the ambulance resource is deployed as effectively as possible.

Reducing health care demand by enabling self-care

We routinely share important messages with our local communities and general public, encouraging them to make the best possible choices when it comes to seeking care. This aims to reduce pressure on emergency departments and other urgent care services. These messages are delivered through channels including social media, the media and advertising spaces in high footfall areas, all created and pushed out in partnership with system partners. Messages include:

• Use of NHS 111 online and over the phone.

• Signposting to pharmacies and self-care options in the event of minor health concerns.

• Directing patients to Urgent Treatment Centres (UTC) where appropriate.

• Bank Holiday messages, ensuring patients are aware of available services.

• Emphasising the importance of vaccination as a preventative measure, both for winter illnesses and childhood diseases.

• Sharing national campaign messaging provided by NHS England.

Provision of effective alternatives for public access to prevent Emergency Department (ED) attendance with signposting

Access to general practice has been a significant improvement focus for the ICB. A system wide improvement programme has supported practices in making it easier for patients to access care – including improved telephony systems. There are now approximately 15% more GP appointments available than in 2019, with some appointments routinely offered at weekends and evenings. Practices have also been working together to provide additional care in trials of ‘locality hubs’.

NHS 111 is the main portal for access of NHS services out-of-hours, but can also be accessed in-hours if required. There have been an average of 1,310 calls per day over the last 12 months, with 535 of these calls being ‘in-hours’ and 775 calls being classed as ‘out-of-hours’. 22% of the calls to 111 are referred onto integrated urgent care/ED, 17% of calls are referred to primary care, 15% to a UTC and 13% require an ambulance to be arranged. Just over 18% of these calls require no onward referral. Call answering time is on average 60 seconds with 6.98% of calls abandoned. In a similar manner to WMAS services, BSOL ICB do not directly commission NHS111 services, but work closely as associate commissioners with Black Country ICB who commission this service on behalf of the West Midlands with Derby and Derbyshire ICB for the Midlands Region.

BSOL has six UTCs across the footprint; these can be accessed either by walking-in or via direction from NHS 111. They provide an alternative pathway away from ED for those patients who require swift medical attention with urgent but non-life-threatening conditions. The UTCs can also offer clinical telephone advice to ambulance crews on the scene and can accept conveyances when and where agreed. On average, 714 patients have been treated daily within UTCs over the last 12 months. A full review of UTC provision was instigated in May 2024 to ensure it meets the needs of both our local population and new national guidance published in October 2023.

The ‘Pharmacy First’ Service commenced on the 31st January 2024 and enables community pharmacists to complete episodes of care for patients without the need for the patient to visit their GP. Across BSOL 93% of pharmacies have registered to provide the service which includes referrals to community pharmacy for minor illnesses, previously commissioned as Community Pharmacist Consultation Service (CPCS), and seven new clinical pathways which include uncomplicated urinary tract infection, shingles, impetigo, infected insect bites, sinusitis, sore throat and acute otitis media.

Provision of effective alternatives for health care professional access to prevent ED attendance

The Urgent Community Response (UCR) team, provided by Birmingham Community Health Care Trust (BCHC) and UHB community provision, provides urgent care for people in their homes, helping to avoid hospital attendance. Referrals can be made directly by GPs and there are regular contacts with WMAS

each day to divert patients to this pathway if appropriate. There are in the region of 60 referrals a day for UCR. We are currently reviewing the service offered to ensure that as many patients as possible can be treated safely by the team. Patients can also be admitted to the frailty virtual ward, here a patient can receive close monitoring in their own home with consultant oversight if required.

‘Call before you convey’ is a direct service available to WMAS colleagues whilst with the patient in their own home, offering different pathways to use where appropriate, other than hospital attendance. This service is primarily aimed to support patients over the age of 75 years, offering diversion into the UCR or wider community services. Since the commencement of this service in December 2023 there have been an average of just over 65 calls per week equating to nearly 10 patients per day.

For those with mental health needs, where there is no physical health need to address, discussion is facilitated directly with mental health provision to determine the best way to address the care required, with ED avoidance where at all possible.

Effective management within UHB to reduce ED overcrowding

Whilst a number of initiatives are being undertaken across the NHS to assist in reducing delays and congestion within EDs, we have set out below an example of a number of initiatives that have been implemented at UHB with the aim to reduce congestion in the ED.

The Rapid Assessment and Treatment (RAT) team assess patients arriving by ambulance on arrival, organise diagnostic tests and initiate treatment. In the event that there is a lack of flow out of the assessment area, the team undertake the same process on the ambulance in order to reduce delays. Those patients who are sufficiently mobile and fit to wait in the main seated waiting area are directed there to reduce demand for majors cubicles and thus rapidly release the paramedic crew back into the community.

An escalation process operates which makes use of defined areas within ED to accommodate patients at times of surge in demand. Staff are assigned to the area to maintain safety and the area is stood down once sufficient capacity has been released.

The ED have a range of services they can refer into at the point of triage. The most frequently utilised of these are the on-site primary care service and the Same Day Emergency Care (SDEC) service. The primary care service has capacity for around 250 patients a day (66 at QEH) across the three UHB ED sites, typically presenting with a minor illness. The SDEC service treats ambulant patients on an emergency day case basis in order to rapidly diagnose and commence treatment for a wide range of presentations. Typically 39% of admitted patients are cared for in this manner at the QEH. The Frailty SDEC and Emergency Observation Units are also available to the triage team.

A clinical site integrity team co-ordinates the clinical movement of patients across each site at UHB. Key tasks include the allocation of patients to available capacity to ensure optimal utilisation and the management of the ‘medical push’ model whereby patients waiting admission are transferred to the allocated ward in advance of planned discharges leaving the ward, thus reducing the occupancy of the ED. The team are in frequent dialogue with all clinical specialities to co-ordinate discharges, prevent the spread of infections and ensure site safety is optimised at all times. This team also chair regular site integrity meetings with all clinical areas to ensure any operational issues are allocated to the appropriate team for timely resolution.

A key priority for all clinical specialities is the reduction of length of stay within the acute setting. A range of improvement activities are in train to ensure all specialities achieve or surpass benchmarked

performance levels. With emergency demand increasing each year, this activity is essential to ensure all patients can be accommodated in an appropriate timescale.

Prompt and effective discharge processes from all providers to final destination

A single transfer of care hub approach was implemented by UHB, BCHC, Birmingham City Council and Solihull Metropolitan Borough Council in May 2024 to improve the flow of patients out of the acute hospital and into community services. The new process enables fewer handoffs between teams and will enable hospitals to ‘free up’ beds earlier, and therefore, admit patients from ED in a more timely way.

The package of measures set out above demonstrate the focus of the NHS and wider partners locally in addressing issues across the urgent and emergency care pathway within the resources that are available. The is important as nationally NHS England also provided WMAS with additional resources in last financial year (£24m) on a recurrent basis to support additional ambulance crew hours on the road and the best use of resources required for ambulance handover delays to be minimised.