Dear Ms Berry,

Thank you for your letter of 21 March 2024 in relation to the Regulation 28 report to prevent future deaths, following the inquest into the death of Jean Walker. This was issued to:
1. The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU
2. The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT. I would like to start by offering my deepest condolences to the family of Mrs Walker on behalf of the NHS West Yorkshire Integrated Care Board. I am sorry for their loss. I hope that this letter provides reassurance of our collective commitment to delivering services that meet the needs of the population within Yorkshire and the Humber and the lessons learned. You asked for a response from the NHS West Yorkshire Integrated Care Board (WYICB) regarding the following areas of identified concern, the actions that are being taken and the timelines that are being taking with our system partners to put in place improvements. I am responding on behalf of NHS WY ICB as the lead commissioner of services from Yorkshire Ambulance Service (YAS) in relation to the following:  The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a (Category 2) call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.

 There was a significant delay in handing over patients at hospitals which meant they had prolonged waits and were unable to respond to other emergency calls.

Background It is helpful for our learning to understand the wider context at the time of Mrs Walker’s death, to ensure that all relevant issues are considered. The winter of 2022/23 was a period of extreme pressure across the health and care system, due to a number of unique factors. During this time, the ambulance service was similarly affected nationally, including YAS. Pressure was also evident within the wider healthcare system in Yorkshire and the Humber, with associated difficulties in the timely discharge of patients to the most appropriate care settings. During this period, patients and families faced delays in assessment and treatment, for which I am truly sorry. As a consequence of this, patient flow through acute hospitals was significantly impacted. There were some hospitals with queuing ambulances. This was all exacerbated by very high levels of Covid and Influenza, coming at the same time as a national spike in Strep infections in children, as well as high levels of staff sickness absence throughout all areas of the NHS. As a result, overall ambulance response times increased, and during November 2022, the mean response time for ambulances (Category 2) within the South Yorkshire Integrated Care Board (SY ICB) area was 55 minutes and 9 seconds. I am sorry we were unable to provide a better service at this time.

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. To support recovery, the plan set out two key ambitions:
• Patients being seen more quickly in Emergency Departments: 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 and to improve performance and allocate additional investment. This investment was 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 more timely response and meet increasing demand. Within the Yorkshire and Humber region there have been improvements in response times. For the financial year ending March 2024 the mean (Category 2) response

time had reduced to 32 minutes and 26 seconds, within SY ICB the mean response was 31 minutes and 45 seconds. Hospital Handovers and Ambulance Turnaround Times The correlation between handover delays at Emergency Departments and overall ambulance response times is widely acknowledged. Handover times vary amongst our acute trusts in the region. We seek to ensure the root causes are understood. Alongside this handover time, the full turnaround time includes how long it then takes ambulances to be ready to take another assignment. During the calendar month of November 2022, the mean ‘turnaround time’ within South Yorkshire was 58 minutes and 12 seconds. This is well outside the expected standards. The most recent calendar month of reporting (April 2024) showed that the mean turnaround time for ambulances had reduced to 49 minutes and 48 seconds, showing some improvements. Work continues to support further improvements. In particular, in collaboration with the acute trusts, YAS has implemented targeted Quality Improvement initiatives to improve handovers. This helps further reduce the amount of ‘lost ambulance handover time’ and allow ambulances to return to respond to emergency calls in a more timely manner. As part of operational planning for 2024/25, SYICB has set out an improvement trajectory for hospital handover times to be reduced to an average of 19 minutes. This will require continued focus on quality improvement and leadership to support delivery. Further support measures YAS and Sheffield Teaching Hospitals NHS Foundation Trust (and other trusts within South Yorkshire) have agreed a new Joint Escalation Action Plan (JEAP) for when system pressures increase, this plan provides specific actions that organisations must employ to support the improvement of ambulance handover. This is the specific element of the turnaround time that involves the ambulance handing over to the Emergency Department. Handover times from ambulances to Emergency Department teams in South Yorkshire were 39 minutes and 49 seconds during the winter period (November 2022 to March 2023). Handover times had reduced to 32 minutes and 37 seconds (November 2023 to March 2024). I am pleased to report that a further reduction in handover times in April 2024 within South Yorkshire has been achieved with mean handovers within South Yorkshire being achieved in 28 minutes and 24 seconds. Implementation of ‘Duty to Rescue’ protocol - this protocol was introduced ahead of the winter period (2023/24) and is now enacted at times of significant operational pressure. On occasions when there are high number of ambulances waiting to handover patients, the protocol allows for senior clinical decision makers from YAS and our hospitals to agree to the rapid handover of a patient who is deemed at immediate clinical risk of deterioration and release an ambulance crew to attend to a

999 call, or one who has been awaiting conveyance and is deteriorating. The introduction of this protocol has been welcomed by all parties and allows for clinical risks to be better managed in the system. Alternatives to Accident and Emergency (A&E) Departments – 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 avoid hospital attendance where appropriate, and also gives direct access pathways to clinicians for Same Day Emergency Care (SDEC) at local hospitals, which allow ambulance crews to bypass A&E for suitable patients and therefore improve hospital flow and ambulance turnaround. The EOCs have continued to invest in the clinical workforce utilising 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 referral processes to other services diverting demand into alternative more appropriate care pathways and have recently brought online partners to assist with triage of Mental Health concerns. The EOC currently push on average 2,809 incidents per month to alternative response providers with on average 2,392 being accepted. System Coordination Centre (SCC) has also been developed over the past year. The SCC is a central co-ordination 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 I can confirm this Regulation 28 – Future learning from deaths notification has been presented to and discussed at the YAS Clinical Quality Oversight Group to share the matters of concern raised across the Yorkshire and Humber region, this in turn will be escalated to the Executive Leadership Board which has oversight of the Ambulance Service in Yorkshire. 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 information provided in this letter offers some assurance on the improvements we have made with our partners, resulting improvements in patient safety and the commitment to continue to deliver improvements across the system. If you require any further information, please do not hesitate to contact me.

Dear Ms Berry,

Thank you for your report of 20 March to the Secretary of State for Health and Social Care regarding the death of Jean Walker. I am replying as Minister with responsibility for urgent and emergency care services.

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Walker’s 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 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 and capacity at Yorkshire Ambulance Service NHS Trust (YAS) as a result of handover delays at hospitals. These concerns were also raised directly with the responsible NHS Integrated Care Board.

In preparing this response, my officials have made enquiries with NHS England (NHSE). I am informed that the West Yorkshire Integrated Care Board will shortly be responding on the specific local actions being taken to support ambulance response times. NHSE has advised my officials that investment is being made for additional crews and fleets as well as clinical workforce in the Emergency Operation Centre to support decision making on the phone and support crews attending calls at home. Further, I understand that there is work with partners across the region to address handover delays including implementation of a Duty to Rescue protocol to release crews from hospitals to respond to immediate community emergencies.

As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the NHS is facing and the impact on 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 a target for this year to reduce Category 2 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:

recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-2024.pdf

Your report highlights reduced ambulance resource in the Yorkshire region at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, 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.

Since publication of the plan in January 2023, there have been improvements in performance. At a national level 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 over 27%. In the Yorkshire region, average Category 2 response times were over 9 minutes faster compared to the previous year, a 23% reduction. Regarding handover delays, in April the average patient handover time in the Yorkshire region was 29 minutes 2 seconds.

Yours,

HELEN WHATELY