Dear Mr Sullivan Re: Regulation 28 Report to Prevent Future Deaths Dated 29 March 2018 write in response to the Report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013, dated 29 March 2018, for Mr Matthew Faulkner, which was issued to East of England Ambulance Service, Lister Hospital, Luton and Dunstable Hospital and Princess Alexandra Hospital The Report was received via email from your Senior Support Office Jon Monday 9 April 2018. We offer our sincere condolences to Mr Faulkner's family and friends for their loss_ This response is limited to Part 5 of the Regulation 28 Report "Coroner's Concerns; concern numbered (4) That there are still significant delays open handover to hospital, exacerbating the lack of Ambulances being available to answer emergency calls: note concerns numbered (1) (3) are directed to East of England Ambulance Service ("EEAS") Firstly, we would respectfully submit that Luton and Dunstable Hospital were not made aware of an inquiry having been opened on 6th June 2017 into Mr Matthew Faulkner's death and of the Inquest held on 27th March 2018. As such, Luton and Dunstable Hospital did not have an opportunity to take part in the Inquest and make submissions in respect f any risks identified in the course of the inquiry andl or respond to any submissions made by the Interested Persons who attended the Inquest on 27th March 2018. On May 2017 , between 17:00 and 22.00 hours, 19 ambulances were delayed at the Luton and Dunstable Hospital. This consisted of 11 ambulances under 30 mins and 8 ambulances under 60 mins, amounting to 368 minutes in total. As it was the Tuesday post Bank Holiday, ED attendances were expected to be high and indeed 326 patients attended across the 24 hour period, higher than the rolling 30 day average of 296. 88 patients arrived by ambulance which is within normal daily expectations_ The bed reports from that indicates high numbers of patients in the department at Apm there were 67 patients in ED and 8pm, 58 patients, which would have caused some overcrowding within the department Similarly due to the Bank holiday weekend, discharges were reduced compared with normal; the Trust already had taken steps to mitigate this by using one contingency ward of Chairman: Simon Linnett [HS 'C] Chief Executive; David Carter Luton and Dunstable UCL Medical School Clinical University Hospital Teaching Hospita NHS Foundation Trust May 30th day

an extra 18 beds full, and creating two "outlier bays" within the Surgical bed base, creating 12 further contingency beds_ Flow ut of ED was challenging despite this, with consequent ambulances offload being compromised. It is worth noting that the hospital typically has up to 60 patients whose discharges are delayed due to issues outside the hospital. Generally the L&D's performance regarding ambulance handovers is considered to be very reasonable_ We have long adopted this metric as one of our triggers for patient flow escalation, which is monitored carefully throughout a 24 hour period. We always act upon handover delays if it becomes apparent that flow has reduced, and this is contained within our four times daily bed report: The escalation process involves input from an executive director and one of the medical directors Whilst there is always room for improvement; the Weekly Sitrep ending 4th June 2017 shows that we had no ambulances waiting over 60 mins throughout the whole week: Attached to this letter is the East of England Ambulance service data for the period in question, showing the position of the L&D and all other trusts served by EEAST. The L&D ED processes are designed to ensure timely handovers with joint decision making taking place between the ambulance crew and the ED nurse in charge with regards to safely offloading patients. If there are no cubicles immediately available, the duty ED consultant is made aware and becomes involved_ and the hospital control room are tasked with resolving the situation_ AII ED patients are prioritised by clinical need and a continuous clinical risk assessment of all patients is undertaken through the process of "ED rounding" this is based upon the Bristol Patient Safety Checklist as advocated by NHS Improvement This may mean that at times patient who has not arrived by ambulance may be given priority above an ambulance patient. We are aware that other Trusts have taken the decision to cohort patients while still on ambulance trolleys and still in the care of ambulance crews. This does nothing to resolve the release of ambulance crews and indeed removes more crews from attending to 999 calls. In response to this, EEAST created Patient Safety Intervention Team (PSIT) consisting of 5 separate geographical teams each of between 3 and 6 clinical staff, These teams would be deployed into hospitals that had problematic ambulance offload problems, taking over the care of these patients while the hospital was unable to accommodate them and thus releasing the ambulance crew and vehicle back into active response duty: Although these PSIT teams were deployed on basis to hospitals across Hertfordshire, they have never been sent to the L&D. It is the Trust's firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number f other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this_ We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it. We will transfer patients to wards where beds will shortly become available even if the space has not become daily yet

available, thus temporarily increasing the capacity of a ward (this is referred to as "boarding") _ All parts of the NHS are experiencing growing pressure with the increased demand in services and Luton and Dunstable Hospital are committed to working with all health and social care providers , as needed; to improve the quality of care and coordination between diverse services to ensure patients are kept safe Clearly, as partners working together with EEAS, we will continue to work collaboratively to improve services we provide to our patients and the wider local populations, as needed. Please do not hesitate to contact me if you require any further details_

Dear Mr Sullivan write further to an email received from Senior Support Officer , on 9 April 2018 to which she attached Regulation 28 Report t0 Prevent Future Deaths_ This report was made by you following the inquest into the death of Matthew Luke Faulkner; which concluded on March 2018, and the concerns you raised are outlined below: At the time of this incident, demand on the EEAST far outstripped the resources available to them; That the current position regarding demand outstripping available resources is not significantly different to that in 2017 . That the demands placed on the EEAS by the public are not sustainable. With, in the region of, only 60% ambulance attendances resulting in admission to hospital for urgent care_ That there are still significant on handover to hospital;, exacerbating the lack of ambulances being available to answer emergency calls. In April 2017 NHS England and NHS Improvement commissioned an independent service review to provide recommendations on the Best Service Model, Pricing Review, Capacity and Demand Analysis and the Commissioning/Contract model. This was review was completed by Deloittes and ORH, company specialising in operational modelling for emergency and health services. The findings were published on 11h May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand This is now factored into our emergency operations contract which will see a 15% increase over the next years_ This funding will enable the Trust to increase its frontline patient staff by 330 full time equivalent by 2020/2021. enclose a copy of the service review for your information. We are planning to arrange a further briefing for HM coroners in the coming months_ Whilst this independent service review was undertaken, nationally all ambulance services made significant changes to the way we respond to our patients due to the implementation of the Ambulance Response Programme: The Trust commenced the implementation of these new standards on the 18 October 2017 , which involved allowing call handlers more time to assess 999 calls to determine which patients required an immediate response; and changes to the call categorisation. The new system allows for early recognition of life threatening conditions end is designed to free up more vehicles and staff to respond to emergencies. understand the Trust's former Medical Director; wrote to you Chief Executive: Robert Morton Chair: Sarah Boulton WWW eastambnhsuk THISISEEAST Innovallve; Responslve; Excellent Atwove communlty focused Alwav: Patleni drver Wey 27th May delays two facing being

in October 2017 outlining these changes and further detail can be found on: WWw englandnhs_uklurgent: emergency-care The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter. These teams were deployed to emergency departments across the region where handover delays were continuing past 45 minutes, where no immediate resolution of the situation is apparent and patients are waiting for an ambulance response in the community: The aim was to minimise patient wait and maximise the availability of ambulances; The teams worked collaboratively with emergency department staff to maintain the safety of patients in the department along with ensuring awareness of those 999 patients who are waiting for a response: This scheme stayed in place until March 2018. Following the risk summit that took place in January 2018, an independent harm review was commissioned by NHS Improvement: This review was conducted by the Medical Director at NHS Improvement; an independent medical consultant and two of the Trust's Clinical Commissioning Groups. Recommendations from risk summit are outlined below: Improved capacity and demand forecasting for the ambulance Trust Early escalation of hospital handover delays, which has resulted in a new regional handover protocol and operating procedure. That the Trust to continue to support reduction in handover to clear times Review of the PSIT and HALO (Hospital Ambulance Liaison Officer) functions Additional staff in the Emergency Operations Centre, specifically clinicians to support the Emergency Clinical Advice and Triage Centre. This will enable appropriate prioritisation and more lower cases to be triaged t0 free up resources most in need: Collaboration with CCGs to review the process of inter-hospital transfers_ This review also identified national learning for all ambulance services too: Stricter adherence t0 welfare call process protocols Review call triage scripts for patients who have fallen Commissioners to support regional services e.g: falls response team National review of emergency services e.g. if patient fallen and no harm, specifically in relation to care home services Review of certain care home policies eg: no-lift policy Application of end of Iife care processes consistently in care homes Up-to-date directory of services
e.g: GPs to call ambulance services directly to enable appropriate information sharing hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way: We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls_ Please do not hesitate to contact me should you require any further information.

Dear Mr Sullivan Matthew Faulkner (Deceased) am writing in response to your Regulation 28 report to Prevent Future Deaths, dated 29 March 2018, regarding the above named. was saddened to learn of the circumstances of Mr Faulkner's death on 30 May 2017_ Whilst | am aware that this Trust was not directly involved in the Inquest, entirely understand why, having heard the evidence the East of England Ambulance Service (EEAS); you issued this report to ourselves, Luton & Dunstable Hospital and the Princess Alexandra Hospital in Harlow: As you will be aware, there is a national concern with regard to ambulance handover times at Emergency Departments and it was pleasing to hear recently that the Government are allocating additional funding to the ambulance service to assist with this. However; in this particular instance and in general, we are acutely aware of how ambulance and hospital services need to work together in improving the Iocal situation. In January 2017 we identified ambulance handover times as a challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim to reduce handover times to the meet the national standard of 10% within 15 min of arrival, thus releasing ambulance crews in a timelier manner Using the principles of lean management; all non-essential tasks were removed from the handover process significantly reducing the workload of the nurse responsible for handover: This reduced the time of handover from 14 min per patient to 5 min significantly improving the department's ability to meet the peak demands In practical terms this increased our capacity to meet the target for 6 patients in a 30 min period, increased from 2 patients in a 30 min period: Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder from key being

It is noteworthy that at times demand will out strip capacity leading to breaches in the 15 min target for some patients, whilst the average handover time may remain below 15 minutes: However, as a result of the work described above the department achieved some of the best average performance in the region and managed to maintain this until September 2017 as demonstrated in the graph below. Average Time to Handover Time Ambulance J4 CILl UJ 007 H Be0 0/ In September 2017, we introduced new computerised patient record and observation systems which regrettably, though understandably, slowed down patient throughput; specifically in the Emergency department This in combination with winter pressures caused the handover time to slip As a consequence of introducing the new systems we are regrettably unable at present to confirm, with certainty, the actual Emergency Department activity flow of patients , numbers waiting at point) on 30" May 2017 to explain the ambulance delays relevant to this incident: We are conducting a focus week in June 2018,mirroring the methods we used to improve the situation last year; in order to bring performance back to the same levels as in April 2017 . Having achieved the improvements required, the performance will be monitored on a weekly basis and focus weeks conducted if performance slips. you will agree that the above measures demonstrate our commitment to ensuring an improvement in ambulance handover times within the hospital setting:

Dear Sir Re Regulation 28 PFD report M Faulkner Further to your Prevention of Future Death report dated 29th March 2018 please find below Princess Alexandra Hospital NHS Trusts response to your concerns in regard to waiting time of ambulances delivering patients to our Emergency Department The Trust are committed to ensuring that delays in offloading patients from ambulances are both minimised and escalated in a timely manner: can assure you that the Medicine Health Care Group have introduced a number of process to prevent delays, these include Refurbishment of the Emergency Department- completed in December 2017 The Emergency Department (ED) team have actively worked to reshape and redesign the physical environment and pathways of care for our patients attending the department. The team have maintained a clear focus on improving a number of areas some of which include the following: Introduction of the Steaming Process Rapid Assessment of patients (RAT) Improvements to the ambulance handover Rapid Assessment of Patients (RAT) The introduction of the RAT process aims to ensure that patients are seen and assessed within 15 mins regardless of their mode of arrival. The RAT process is consultant led: The development to the RAT process is currently run as a Plan Do Study Act (PDSA) improvement methodology, the data collected has been used to develop and refine the process: As formal audits have not been completed however our staff have designed an audit which believe will evidence the impact of the process Improvements to Ambulance handover Our staff have clear understanding that as soon as patients arrive in the ED they are our responsibility. The management of the ambulance arrival process is allocated to a Nurse and Doctor who is responsible for the patients at all times. Chair: Alan Burn CEO: Lance McCarthy WWW pah nhsuk being yet they

Whilst every effort is made to ensure that patients receive their initial assessment within 15 minutes, there are at times of peak demand, or when a number of ambulances arrive at the same time; patients who may have to wait in the designated ambulance queue area which is integral to the ED. There is a clear escalation process which staff will follow should there be an issue with queuing ambulances or a in ambulance handover of greater than 30 minutes. Our staff will initiate the ambulance handover escalation process and the priority will be given to the patient who requires the most urgent attention. In addition between the hours of 07.30 and 02.30 this area is further supported by an allocated Paramedic whose role is to continuously monitor the patients in this area and escalate any concerns_ Real time Data The Trust has implemented real time data, which is available to all Emergency Department staff, allowing timely escalation of issues and redeployment of resources across the Emergency Department: The Trust continues to work at improving the care provided to our patients and will continue to monitor that the improvements in our processes have made a positive impact and will continue to reduce the waiting times of emergency ambulances delivering patients_ The Trust hopes You are reassured by improvements made at Princess Alexandra Hospital NHS Trust which aim to reduce the risk of any future deaths in relation to delays for emergency ambulances