Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Nicola Emma Owens who died on 5 October 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 31 January 2025 concerning the death of Nicola Emma Owens on 5 October 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Nicola’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Nicola’s care have been listened to and reflected upon. Your Report raises concerns over delays in ambulance attendance due to ambulance unavailability, with this delay being significantly contributed to by handover delays in hospitals. This, in turn, is contributed to by backlogs of patients who are fit for discharge but are awaiting social care packages. I was very sorry to read the Coroner’s conclusion that Nicola’s death was preventable, and that the unavailability of an ambulance to convey Nicola to hospital for necessary emergency treatment sooner resulted in the terminal cardiac event. Ambulance response times and handovers

NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.

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 Operation Planning Guidance sets out that the NHS should improve ambulance response times and Accident and Emergency waiting times compared to 2024/25, and that Category 2 ambulance response times should not average more than 30 minutes across 2025/26. The guidance also sets out some immediate tasks for 2025/26, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 March 2025

including to reduce avoidable ambulance dispatches and conveyances and reduce handover delays.

The NHS is working more closely with local authorities to improve timely discharge of patients and has developed discharge metrics to monitor performance improvements.

Patients being rehabilitated into the community

NHS England recognises that delayed discharges have a significant impact on hospital flow, capacity and ambulance handovers. In order to address this, NHS England is strengthening the use of Discharge Ready Date (DRD) data in order to gain a clearer understanding of discharge delays and their key contributing factors.

The aim of embedding DRD in operational decision-making is to:
• Identify and quantify delays at local, regional and national levels, enabling targeted interventions.
• Improve coordination across NHS teams by providing real-time insights, supporting better planning and resource allocation.
• Enhance system-wide decision-making through improved forecasting, ensuring capacity is optimised to facilitate timely discharges.

The use of this data-driven approach is helping to improve patient flow, reduce hospital pressures, and ensure that patients who are medically ready for discharge can transition safely and efficiently.

NHS England has also published the 2025/26 Better Care Fund (BCF) policy framework and planning requirements, working alongside the Department of Health and Social Care (DHSC) and Ministry of Housing, Communities and Local Government. The BCF framework supports local systems to jointly agree plans across health and care, including supporting the flow of patients through UEC.

For 2025/2026, changes in funding include:
• The NHS minimum contribution to Adult Social Care, which is one of the mandatory funding streams within the BCF, will increase by 3.9%.
• The Discharge Fund, which is £1 billion for 2024/2025, has been embedded within the NHS minimum contributions to allow systems greater local flexibility in how they utilise this funding to address flow issues.

NHS England will be working with local areas to support them to maximise the impact of this investment over the coming year, by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including Local Government Associations, Directors of Social Services, and Care and Health Improvement advisors to support local systems to improve timely discharge of patients.

My regional colleagues from the North West were also asked to review your Report. They have advised that the Integrated Health and Social Care Programme in North Mersey is focusing on three main workstreams, to improve UEC services. These are outlined below.

1. Admission and Attendance Avoidance

There is specific focus in the workstream to reduce the need for North West Ambulance Services (NWAS) to convey patients to hospital, by increasing the use of services in the community, NHS 111 and other dispositions. NWAS, Mersey Care NHS Foundation Trust (MCFT), the local authority and the University Hospitals of Liverpool Group are working collaboratively to embed a Single Point of Access using NHS England’s framework. A Single Point of Access is intended to simplify access to services by offering clinicians advice and guidance to support onward referral, ensuring patients get the right care for their needs quickly and safely, and to improve patient outcomes regardless of where they present.

There is also work underway to reduce ambulance handover times and increase the number of streaming options away from the emergency department and into services across acute hospitals. There has been difficulty consistently utilising Frailty Units, Same Day Emergency Care Services as well as other services due, to operational pressures. Work supported by Emergency Care Improvement Support (ECIST) and the Advancing Quality Alliance (AQuA) with the acute trust will help to improve access to services and reduce ambulance turnaround times. There have been significant improvements in recent ambulance turnaround times, partly due to additional corridor and surge capacity being made available on the two sites.

The revised Frailty Plan forms part of Volume 2 of the North Mersey Urgent and Emergency Care Programme. This plan focuses on using falls and frailty services in the community to reduce the need to convey patients to hospital and to contribute to greater availability of NWAS emergency vehicles when needed.

2. Acute Length of Stay

There is a focus on ward processes to help reduce internal delays, reducing the length of time patients stay in hospital and creating capacity and flow out of the emergency department, which all contribute to reducing ambulance delays.

3. Acute Discharge

This is focusing on operational issues such as long length of stay or no criteria to reside issues relating to patients needing onward care, and is working to improve the utilisation of different discharge pathways, decreasing the over- reliance of pathway 3 bed capacity in community care (for those with the highest level of complex needs, who require discharge to a care home placement).

Each of the above workstreams have had an impact on increasing flow through the Emergency Department for patients who require a hospital admission, and the programme is currently being revised with a greater emphasis on prevention, in line with national policy. This will be presented to the UEC Programme Board for sign off. NHS England have asked regional colleagues for the date in which this sign off is expected to happen and are awaiting a response. NHS England can undertake to update the Coroner on this in due course.

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 Nicola, 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 Ms Bhardwaj

Thank you for the Regulation 28 report of 31 January 2025 sent to the Department of Health and Social Care about the death of Nicola Emma Owens. 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 Owens’ death and I offer my sincere condolences to their 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 regarding prolonged ambulance response times, operational pressures faced by the North West Ambulance Service and the impact of delayed social care packages on hospital capacity and ambulance handover delays.

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

The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years and we are committed to restoring ambulance response times to the standards set out in the NHS Constitution. 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.

As a first step, 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. 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. 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.

The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:

• working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes,
• improving ambulance ‘hear and treat’ service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone,
• ensuring all 999 ambulance calls classified as Category 3 and 4 are clinically navigated, validated and where appropriate triaged in ambulance control centres, or in Single Points of Access.

Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.

We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.

Later in the Spring, to accompany the additional investment in the NHS, the Government will publish a 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, we will shortly set out further actions to be taken during 2025-26 to support improvements to urgent and emergency care performance this year.

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