Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Diana Fairweather-Purkis who died on 3 October 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 February 2025 concerning the death of Diana Fairweather-Purkis on 3 October 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Diana’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Diana’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 Diana’s family or friends. I realise that responses to Coroners’ 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 that there is insufficient ambulance service availability / resource to enable ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times, and that there are excessive delays in patient handovers between ambulance crews and hospital staff. In Diana’s case, I note that the initial target response time for the Category 3 ambulance was 2 hours before it was upgraded to Category 2, but unfortunately an ambulance did not attend until 9 hours and 56 minutes after the initial call to NHS 111. Ambulance availability and response times NHS England recognises the significant pressures on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. Improvements to Category 2 response times will have a positive impact across ambulance performance generally, including Category 3 responses. NHS England also recognises the need to increase ambulance capacity through growing the workforce, improving flow through hospitals, reducing handover delays, speeding up discharges from hospital and expanding new services in the community; National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

16 April 2025

all of which support improved patient flow and ambulance response times. The NHS is working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements. Response times for Category 2 ambulance calls have improved; over the 2023/24 year, the average response time was over 13 minutes faster compared to the previous year. NHS England’s regional teams are continuing to work closely with commissioners, Integrated Care Boards (ICBs), acute NHS providers and ambulance services to implement plans to continue to improve patient handovers. The 2025/26 priorities and operational planning guidance sets out that the NHS should improve ambulance response times and Accident and Emergency (A&E) waiting times compared to 2024/25, and that Category 2 ambulance response times should average no more than 30 minutes across 2025/26. The guidance also sets out some immediate tasks for 2025/26, including to reduce avoidable ambulance dispatches and conveyances and reduce handover delays. NHS England has also engaged with North East and North Cumbria Integrated Care Board (NENC ICB), who I note your Report was also addressed to, on the concerns raised in your Report. They advise that since the creation NENC ICB in July 2022, there has been significant investment of additional resources into ambulance services to increase capacity and availability. Over £40 million of additional funding, made up of local ICB investment and a share of nationally funded NHS England growth monies, has been made available to the North East Ambulance Service (NEAS) since 2023/24 to increase the number of vehicles on the road and also strengthen clinical advisory services. NEAS have established an Integrated Urgent Care Clinical Assessment Service (IUCAS) which includes paramedics, nurses, advanced practitioners, pharmacists, GPs and clinical specialists who provide enhanced clinical support to call handlers and patients ringing 111 and 999. Senior clinical advisors (clinicians) provide additional clinical assessment via telephone triage, improving the journey and experience for our patients by ensuring they can pass through to services quickly and efficiently. The team also promotes self-care and provides advice and support for patients at home, facilitating onward referral where necessary to a range of primary and secondary care services. By being able to increase the number of patients who are treated and discharged in the community, the IUCAS helps to reduce pressures on ambulances, emergency departments and other NHS services. With regard to ambulance performance and the target response times, NEAS are consistently the highest performing ambulance provider in England across all 4 response time categories, and they continue to implement system-wide improvement programmes in conjunction with NENC ICB and acute hospital providers to further improve response times throughout 2025/26 and work towards achieving the NHS constitutional standards. Handover delays in hospital

Ambulance handover delays are a priority area of focus for NENC ICB, NEAS, and acute provider NHS Foundation Trusts across the NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICB, Foundation Trust, Ambulance Trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.). Alongside the wider ICS programme, there have also been individual improvement programmes taking place across Foundation Trusts to reduce handover delays. A strong example of this is the work that has taken place at South Tees Hospitals NHS Foundation Trust to make tangible improvements to their internal processes, resulting in increased flow through the Emergency Department and reduced average handover times. Average ambulance handover times are improving after a difficult and challenging winter period and, in the last 3 weeks, the average handover time has been less than 20 minutes across the NENC area, just above the constitutional standard of 15 minutes and significantly below the target of 45 minutes in the 2025/26 NHS operational planning guidance. There have also been significant reductions in the number of ambulance handovers in excess of 60 minutes, the threshold beyond which we know patients are at an increased risk of experiencing harm. These improvements have been delivered whilst the demand for ambulances has continued to rise, and general & acute bed occupancy has remained above 92% across NENC. There continues to be a strong focus on reducing handover delays, so that ambulance crews can be released back onto the road as quickly and efficiently as possible to respond to patient demand in the community. This is evidenced by the consistently strong performance of NEAS across the four categories of ambulance response times compared to other ambulance services in England. 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 Diana, 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 Mr Appleton,

Thank you for the Regulation 28 report of 17 February sent to the Department of Health and Social Care about the death of Diana Fairweather-Purkis I am replying as the Minister with responsibility for urgent and emergency care.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Fairweather-Purkis' death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over ambulance service pressures, the long waiting times for an ambulance and handover delays experienced by patients.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that NHS England and NHS North East and North Cumbria Integrated Care Board are also responding to this report.

The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years.

We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes.

To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010.

We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future.

On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.

There is a national focus to improve Category 2 response time performance as these responses make up over half of all ambulance call outs and incidents within this category are of a high, life- threatening nature. Improving Category 2 response times will improve ambulance performance generally, as more resources will then be available to attend to lower acuity incidents.

The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.

In Spring 2025, to accompany the additional investment in the NHS, the Government will publish its 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future.

In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.

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

Dear Mr Appleton Re: Diana Fairweather-Purkis, deceased (date of death 03/10/2022) In relation to the matters of concern you identified following your investigation, please find the following response from the North East and North Cumbria Integrated Care Board.
1. There is insufficient ambulance service availability/resource to enable ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times. Since the creation of the North East and North Cumbria Integrated Care Board (NENC ICB) in July 2022 there has been significant investment of additional resources into ambulances services to increase capacity and availability. Over £40m of additional funding, made up of local ICB investment and a share of nationally funded NHS England growth monies, has been made available to the North East Ambulance Service (NEAS) since 2023/24 to increase the number of vehicles on the road and also strengthen clinical advisory services. NEAS have established an Integrated Urgent Care Clinical Assessment Service (IUCAS) which includes paramedics, nurses, advanced practitioners, pharmacists, GPs and clinical specialists who provide enhanced clinical support to call handlers and patients ringing 111 and 999. Senior clinical advisors (clinicians) provide additional clinical assessment via telephone triage, improving the journey and experience for our patients by ensuring they can pass through to services quickly and efficiently. The team also promotes self-care, provides advice and support for patients at home, facilitating onward referral where necessary to a range of primary and secondary care services. By being able to increase the number of patients who are treated and discharged in the community, the IUCAS helps to reduce pressures on ambulances, emergency departments, and other NHS services.

With regard to ambulance performance and the target response times, NEAS are consistently the highest performing ambulance provider in England across all 4 response time categories and continue to implement system-wide improvement programmes in conjunction with ICB and our acute hospital providers to further improve response times throughout 2025/26 and work towards achieving the NHS constitutional standards.
2. There are excessive delays in ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff. Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICB, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.). Alongside the wider ICS programme there have also been individual improvement programmes taking place across Foundation Trusts to reduce handover delays. A strong example of this is the work that has taken place at South Tees FT to make tangible improvements to their internal processes resulting in increased flow through the Emergency Department and reduced average handover times. Average ambulance handover times are improving after a difficult and challenging winter period and in the last 3 weeks the average handover time has been less than 20 minutes across NENC, just above the constitutional standard of 15 minutes and significantly below the target of 45 minutes in the 2025/26 NHS operational planning guidance. There have also been significant reductions in the number of ambulance handovers in excess of 60 minutes, the threshold beyond which we know patients are at an increased risk of experiencing harm. These improvements have been delivered whilst the demand for ambulances has continued to rise, and general & acute bed occupancy has remained above 92% across NENC. There continues to be a strong focus on reducing handover delays so that ambulance crews can be released back onto the road as quickly and efficiently as possible to respond to patient demand in the community. This is evidenced by the consistently strong performance of NEAS across the four categories of ambulance response times compared to other ambulance services in England. I hope that this answers your queries. Please do not hesitate to contact me if you require any further information on this.