Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Keith David Foord who died on 3 May 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 December 2024 concerning the death of Keith David Foord on 3 May 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Keith’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Keith’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 Keith’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 raises a concern in relation to the categorisation of ambulances in cases of aortic dissection requiring emergency surgery and inter-facility transfer, and the fact that Keith was categorised as Category 2 rather than Category 1 when there was a critical requirement for emergency surgery. NHS England has separately heard from Keith’s family in respect of the expert evidence from Mr Michael Sabetai on this issue. I also note the family’s concerns around the length of time it took for the Category 2 ambulance to arrive on 2 May 2022, including the impact of the delayed inter-facility transfer on Keith’s chances of survival. I am grateful to the family for taking the time to write to NHS England directly, and I hope that this response addresses all of the points they have raised. NHS England published the National framework for inter-facility transfers in July 2019, which was last updated on 12 December 2024. The framework is intended for patients who require transfer by ambulance between facilities due to an increase in either their medical or nursing care needs. Patients who have immediate life-threatening injuries or illnesses should be transferred within a set timeframe mapped to Ambulance Response Programme National Medical Director for Secondary Care and Quality NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

17 February 2025

(ARP) categories. Similarly, patients with serious or urgent healthcare needs should be transferred in an appropriately commissioned timeframe. Inter-facility transfers (IFT) Level 1 (IFT1) Category 1 As stated in the National framework, this level of response should be reserved for those exceptional circumstances when a facility is unable to provide immediate life- saving clinical intervention such as resuscitation or, in the case of a declared obstetric emergency, when a facility requires the clinical assistance of the ambulance trust in addition to a transporting resource. These requests should be processed through the trust’s 999 triage tool and only those that are deemed a Category 1 under that assessment should receive a Category 1 response. Examples would include cardiac arrest, anaphylaxis, birth units requiring immediate assistance or acute severe life-threatening asthma in an urgent care facility. IFT Level 2 (IFT2) Category 2 This level of response is based on the clinical condition of the patient and the need, or a high likelihood of the need, for further treatment and management at the destination facility rather than the patient’s diagnosis. Immediate life, limb or sight threatening situations that require immediate management in another healthcare facility should receive this level of response. Other examples include patients going directly to theatre for immediate primary percutaneous coronary intervention (PPCI), stroke thrombolysis, or surgery for ruptured aortic aneurysm. These IFT Level 2 patients are mapped to a Category 2 response. Both IFT Level 1 and Level 2 incidents are confirmed emergencies which require life- saving intervention and should be responded to as time critical emergencies and immediately allocated the nearest appropriate response. An IFT Level 1 or Level 2 incident must be treated exactly the same as any other Category 1 or Category 2 community ambulance response, and must not be deprioritised simply because the patients are in an existing hospital or care setting. The framework does allow for clinical discretion to be applied in some cases where the patient’s condition does not precisely meet the definition, but additional considerations are involved. If an ambulance is not immediately available for dispatch to an IFT Level 1 or 2 call, this incident should be escalated within the ambulance operations centre to ensure an appropriate response and maintenance of clinical oversight whilst waiting for dispatch. This means that a clinician requesting transfer for a patient with an aortic aneurysm can advise the clinician in the 999 operations centre of the plan on arrival at the receiving hospital, so that an appropriate clinical priority can be agreed. In December 2024, NHS England amended the National framework to advise that requests for an inter-facility transfer for a patient, where the stroke / cardiology team are accepting patients for immediate intervention (i.e. mechanical thrombectomy or primary percutaneous coronary intervention (PPCI)), should be clinically navigated and prioritised for a Category 2 dispatch.

Ambulance response times NHS England recognises the significant pressures on all NHS services, including ambulances, and has been prioritising improvements to Category 2 response times and urgent and emergency care services. NHS England’s ambitions for 2024/25 have been set out in the NHS priorities and operational planning guidance, which includes improving Category 2 ambulance response times relative to 2023/24, to an average of 30 minutes across 2024/25.

NHS England has also recognised the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow and ambulance response times. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements. Improvements to ambulance response times are also being enabled by addressing excessive handover delays. Rapid handovers are essential to ensure that patients reach definitive care promptly, which includes both those waiting to receive care in the Emergency Department, and those waiting in the community. NHS England continues to work with trusts and services with significant handover challenges at the ‘front end’, alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient flow and allow new patients to be handed over more promptly to Emergency Departments (or, in Keith’s case, to be transferred from the Emergency Department in one hospital and handed over to the cardiac team in another hospital). 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 Keith, 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.