Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Bernhard John Marek 6th January 2023 Thank you for your Regulation 28 Report dated 19/07/2023 concerning the sad death of Mr Bernhard John Marek on 06/01/2023. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Mr. Marek’s family for their loss. Thank you for highlighting your concerns during Mr. Marek’s Inquest which concluded on 31st of May
2023. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention. We recognise it is also very important to ensure we make the necessary improvements to the quality and safety of future services. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future death will occur unless action is taken. The medical cause of death was 1a) Hospital Associated Pneumonia; 1b) Fractured Neck of Femur (operated); II) Squamous Cell Carcinoma Lung, Acute Kidney Injury I hope the response below demonstrates to you and Mr. Marek’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case. The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service and that such delays were not unusual throughout December due to demand and resources. As a consequence, frail elderly patients such as Mr Marek with hip fractures were regularly waiting significant periods of time for the ambulance service. The resource issues faced by the ambulance service were exacerbated by long delays faced by ambulances to offload patients at Emergency Departments. The date of the incident in question, December 2022, fell within a period of documented extreme pressure within the region. North West Ambulance Service (NWAS) declared a number of critical incidents during the weeks leading up to Christmas 2022 and the situation was further exacerbated by ongoing industrial action. In response to the harm identified in this period, NWAS and commissioners shared an analysis of high-risk incidents with the wider system to stimulate reflection and discussion as to how all partners could improve safety. This particularly related to the delays seen in hospital handover. The work of the handover collaborative continues across the North West and improvements

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk have been seen, especially within the area of your coroner’s office, Greater Manchester, achieving the National target of 30 minutes in June 2023 with a monthly average of 29 minutes. The monthly average for Hospital Handover in December 2022, when Mr Marek had his fall, was 1 hour 10 minutes and 13 seconds for Greater Manchester

As you will be aware, the NHS remains a system in recovery following the COVID-19 pandemic and the pressures arising from it and the societal response. As part of this, NHS England has published a series of recovery plans, including one for Urgent and Emergency Care. This contains nine key workstreams covering capacity, workforce, hospital discharge and care outside hospitals. One specific workstream covers increasing ambulance capacity, as it recognises the increased complexity of ambulance call-outs and amount of care provided at scene. The national plan sets a goal to reduce the Category 2 response time performance to 30 minutes this year – itself recognising that resolving the response time issue needs longer-term changes, including additional vehicles and workforce.

The plan sets out several specific objectives to be delivered across all ambulance services:

B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf (england.nhs.uk)

Current performance levels in the North West have improved since the date of this incident. The monthly average response time in December 2022 for NWAS in Greater Manchester for category 2 was 1 hour 52 minutes and 58 seconds, and for category 3 response was 7 hours 1 minute and 9 seconds. The monthly average for June 2023 Category 2 mean performance in Greater Manchester was 22 minutes 48 seconds and for category 3 this had improved to 2 hours 33 minutes and 41 seconds. These are far closer to the Ambulance Response Programme (ARP) standards, and we hope to see further progress as the recovery plan is implemented.

Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the ARP standards in the region.

Actions taken or being taken to share learning across Greater Manchester:

1. Learning to be presented/shared with the Greater Manchester System Quality Group on 21st September 2023. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services.

2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk I hope this response demonstrates to you and Mr. Marek’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided.

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 Mutch, Thank you for your letter of 19 July 2023 to the Secretary of State for Health and Social Care about the death of Bernhard John Marek. I am replying as Minister with responsibility for Urgent and Emergency Care. Please accept my sincere apologies for the delay in responding to this matter. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Marek’s death and I offer my sincere condolences to his family. I am grateful to you for bringing these matters to my attention. Your report raised concerns about ambulance response times by North West Ambulance Service NHS Trust (NWAS) and resource issues leading to ambulance handover delays at Stepping Hill Hospital, Stockport NHS Foundation Trust. In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC). My officials advise me that Greater Manchester Integrated Care, wrote to you in August to provide information on the improvements being made locally following Mr Marek’s’ death which have supported improved ambulance response times and reductions in handover delays. In addition, I understand the CQC has had regular engagement with the North West Ambulance Service and partners to monitor ambulance delays, the plans to address them, and the management of risk. I recognise the significant pressure the urgent and emergency care system is facing. In January 2023 we published our ambitious 2-year Delivery plan for recovering urgent and emergency care services to drive sustained improvements in urgent and emergency care waiting times. Our ambitions for this year are to improve A&E waiting times to a minimum of 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at

content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care­ services.pdf Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received A5 1

£200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. 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. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.   At a national level, we have seen significant improvements in performance this year compared to last year. In winter 2023-24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 12 minutes faster compared to the same period last year, a reduction of nearly 25%. NWAS average Category 2 response times in winter 2023-24 were over 8 minutes faster compared to the same time period last year, a 18% reduction. However, I recognise there is still more to do to reduce waiting and response times down further and back towards pre-pandemic levels – and this is the action we will continue to be taking as part of the government’s commitment to improving NHS services and reducing waiting times. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY A6