Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Colin Wiles who died on 27 March 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 November 2024 concerning the death of Colin Wiles on 27 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Colin’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Colin’s care have been listened to and reflected upon.

My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.

You raised the concern that it does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.

Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If the call is made via a second party, ambulance services should ensure there is a process in place to be assured the caller is able to monitor the condition of the patient, and that they can be called back when the patient is not able to call back or answer a call themselves. If this was not provided in a clear and easy to interpret manner, this is a matter for the relevant ambulance service to resolve locally as a training issue for their call handlers.

You also raised a concern over the waiting times for ambulances to handover patients at Hull Royal Infirmary, which were excessive on 27 March 2023, leading to 160 hours of lost ambulance time.

Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers are essential to ensure patients reach definitive care promptly, which includes both those waiting to receive care in the emergency department (ED), and those waiting in National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

22 January 2025

the community. NHS England are continuing 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 EDs.

To deliver this, the NHS’s ambitions for 2024/25 have been set out in the NHS priorities and operational planning guidance. These are:
• improve A&E performance with 78% of patients being admitted, transferred, or discharged within 4 hours by March 2025
• improve Category 2 ambulance response times relative to 2023/24, to an average of 30 minutes across 2024/25 NHS England’s operational planning guidance has asked systems to focus on three areas to deliver these ambitions:
1. maintaining the capacity expansion delivered through 2023/24
2. increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, improving flow and length of stay, and clinical outcomes
3. continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, admissions avoidance, and hospital discharge. Evidence of the impact of system actions to improve patient flow and relieve pressures on EDs includes:
• tens of thousands more people received the care they needed to return home quickly and safely due to the expansion of same day emergency care (SDEC) services
• on average, around 500 fewer patients a day had to spend the night in hospital because of a discharge delay, and 13% more patients received a short-term package of health or social care to help them continue their recovery after discharge
• urgent community response teams provided 720,000 people with an alternative to going to hospital between April and January 2024
• virtual wards have supported more than 240,000 people to get the hospital- level care and monitoring they needed in the comfort of their own home Additionally, during 2024/25, providers have access to £150 million of funding to support specific local improvement plans for urgent services, including for mental health care. These new improvements will support patients being treated more quickly in A&E or by other services in the community. Up to £150 million will also be available to incentivise the best performing areas and those that improve fastest. The NHS and local authorities will also work together to expand intermediate care services, both in people’s own homes and in community beds, thanks to the additional £400 million Better Care Fund (BCF) available to support further improvements in hospital discharge. There will also be further improvements to, and co-ordination of, community-based services that support people to avoid ambulance call-outs and hospital admissions, by treating people in the most appropriate place for their level of need.

NHS England will also be prioritising:
• improving length of stay for all admitted patients (specifically emergency admissions with a length of stay of 1+ day)
• reducing delays
• improving length of stay in NHS commissioned community beds My regional colleagues for North East and Yorkshire have also engaged with Humber Health Partnership, of which Hull University Teaching Hospitals NHS Trust is a member, regarding the concerns raised in your Report. We note and welcome the actions they are taking to reduce ambulance handover times and restore patient flow. We are advised that the Trust has also implemented a Temporary Escalation Space (TES) and Boarding Standard Operating Procedure to improve patient flow and increase availability of beds for patients attending the Emergency Department. I refer you to Humber Health Partnership’s response to your Report for further information. 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 Colin, 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 Robinson

Re: Regulation 28 Report to Prevent Future Deaths – Colin Wiles

We write further to your Regulation 28 Report dated 24th November 2024 and extend our condolences to the family of Mr Colin Wiles. Below, we address the concerns raised in points (3) and (4) of your report.

(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day, leading to 160 hours of lost ambulance time.

We recognise that delays in ambulance handovers have a significant impact on patient safety, timely care delivery, and ambulance availability for responding to community emergencies.

On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times:

Phase 1: Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire Ambulance Service (YAS) staff were instructed to leave. Phase 2: Two weeks targeting a maximum handover time of 65 minutes. Phase 3: Transitioning to a 45-minute target.

These measures are in line with the North Bank Escalation and Surge Plan, developed by the Humber Health Partnership, of which the Trust is a member, and include the Ambulance Delay Protocol, which provides a structured framework to minimise handover delays and restore patient flow. Key actions undertaken include:

1. Ambulance Delay Protocol Activation: The Ambulance Delay Protocol mandates that ambulance patients should be handed over within 15 minutes of arrival, with no patient waiting longer than 60 minutes. If a delay exceeds 45 minutes with no immediate plan to hand over, the protocol is triggered, requiring:
• Escalation to the Site Manager.
• Identification and transfer of six stable patients from the Emergency Department (ED) to appropriate wards within 30 minutes.
• Priority transfer of patients with a NEWS2 score of less than 4 who do not require isolation.

2. Senior Oversight and Escalation: The Site Team plays a critical role in monitoring capacity risks, initiating escalation protocols, and providing leadership to manage ambulance delays. Escalation actions are informed by continuous assessment of capacity and demand, with operational and clinical leadership ensuring rapid responses to emerging pressures.

3. Proactive Patient Flow Management:
• Revising the Standard Operating Procedure (SOP) to offload up to eight ambulances per hour and facilitate the transfer of ten patients from the ED to inpatient wards.
• Implementing the Pull for Safety process, which establishes a regular patient flow from the ED to assessment areas and wards.
• Utilising escalation areas and reverse boarding protocols to create immediate capacity for new arrivals, as detailed in the policy.

4. Communication and Collaboration:
• Establishing a standardised communication protocol, including regular updates via secure platforms such as WhatsApp, to enhance coordination and decision-making.
• Engaging system partners, including YAS and Integrated Care System (ICS) colleagues, to expedite mutual aid and support ambulance operations.

Since the implementation of these measures, there has been demonstrable progress in reducing handover times and improving patient flow. For example, the Trust’s approach to boarding patients and optimising escalation spaces has been instrumental in minimising the risks associated with prolonged delays.

(4) There appears to be an issue with No Criteria to Reside (NCTR) patients and the ability to hand over patients into ED at Hull Royal Infirmary who arrive in emergency ambulances.

The management of NCTR patients is a recognised challenge that directly impacts ED flow and contributes to ambulance handover delays. NCTR patients are identified as those who no longer meet the Criteria to Reside set out in the national Hospital Discharge and Community Support Guidance but remain in hospital due to delays in discharge pathways.

Between March and April 2023, 20–25% of the Trust's bed base (approximately 180 beds, equivalent to six wards) was occupied by NCTR patients on discharge pathways 1–3. This occupancy severely impacted patient flow and the availability of beds for incoming ED patients. In response, the Trust has undertaken a series of strategic measures to alleviate these pressures. In November 2024 the Trust implemented the Temporary Escalation Space (TES) and Boarding SOP, which provides a framework for managing capacity challenges and improving flow.

Measures Implemented

1. Creation of Additional Capacity:
• Opened a 54-bed NCTR unit on the 13th floor of Hull Royal Infirmary to accommodate patients awaiting discharge, reducing reliance on acute beds.
• Initiated the construction of the Rossmore Intermediate Care Centre, which will provide an additional 60 short-term placement beds for rehabilitation and reablement.

2. Formal Discharge and Flow Improvements:
• Collaborated with system partners to deliver a reduction in NCTR occupancy to 12.6% of the bed base, surpassing the national target of 15%.
• Implemented updated discharge protocols, including:
- Enhanced cooperation with local authorities to align discharge models with available resources and budgets.

- Increased involvement of families and carers in discharge planning to ensure timely and appropriate placements.
- Use of care transfer hubs to manage complex discharges effectively.

3. Operational Measures from the TES and Boarding SOP:
• Boarding Protocols: The SOP outlines structured boarding processes to manage NCTR patients effectively and create capacity in the ED. This includes:
- Identifying and moving up to three patients per ward to temporary escalation spaces (TES) or discharge lounges within 30 minutes.
- Ensuring timely handovers from ED to inpatient wards to free up ED spaces.
• Proactive Discharge Management: Board rounds and huddles on AMU and inpatient wards focus on early identification of patients for discharge, with targets of 30% discharges by 12:00 and 70% by 17:00.
• Zero Tolerance for Delays: The SOP enforces zero tolerance for patients remaining in AMU for more than 24 hours or in ED for over 12 hours, ensuring flow is maintained.

4. Senior Oversight and Escalation:
• The Site Matron monitors ambulance arrivals and ED capacity in real time, triggering escalation actions when thresholds are met.
• Issues affecting boarding or discharge are escalated to the Care Group and Site Matrons, with further escalation to senior leadership if unresolved.

Impact These measures, underpinned by the TES and Boarding SOP, have significantly improved patient flow and reduced the impact of NCTR patients on acute services. Early discharge planning, effective use of escalation spaces, and coordinated efforts across the Trust ensure timely ED handovers and minimise ambulance delays.

Conclusion

We remain committed to addressing the concerns outlined in your report and have implemented targeted interventions to improve ambulance handovers and NCTR management. We are confident that these measures, combined with continued collaboration across the healthcare system, will reduce the risk of future incidents.

If further information or clarification is required, we would be happy to provide it.

Interim Executive Director of Adult Social Care and Health (DASS) County Hall Beverley East Riding of Yorkshire HU17 9BA Telephone (01482) 393939

Director of Locality Wellbeing and Safeguarding RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE INQUEST TOUCHING THE DEATH OF COLIN WILES PROVIDED BY
– HEAD OF SERVICE, SAFEGUARDING AND QUALITY ASSURANCE, ADULT SOCIAL CARE AND HEALTH, EAST RIDING OF YORKSHIRE COUNCIL There are four MATTERS OF CONCERN to note in this regulation 28 report. The local authority can respond only to MATTER OF CONCERN (1) as follows: No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbities and self neglect leading to poor living conditions and increased risk to his safety The evidence submitted to the inquest demonstrates how a Vulnerable Adult Risk Management (VARM) meeting was considered by the social worker in this case but did not happen. Whilst Mr Wiles was resisting formal care interventions and was believed to have the mental capacity to make that decision, he was continuing to engage with professionals and accept some, if not limited help, which was a protective factor. A VARM would more often be requested for those people who are at risk but refusing all contact with services, although a VARM could have been used in this case to assure all professionals that they were doing all they could to support and safeguard Mr Wiles and give Mr Wiles the opportunity to comment on whether there was anything else he thought they could do to support him. The local authority adult social care and health service (ASCH) and the east riding safeguarding adults board (ERSAB) recognise that the use of VARM should be a key consideration and mechanism in the practice system to ensure it is utilised for all people for whom it would be of benefit. There is an opportunity for the system to utilise the VARM process more regularly when supporting people in circumstances like Mr Wiles to ensure that professionals are working together with and for the person concerned and accept that this is an area for continuous improvement. The current VARM procedure is available to all professionals and people in the east riding on the ERSAB website and guides them through the processes and paperwork involved (included as appendix 1). Training is provided to practitioners across the health and care system in the east riding on the use of VARM both through the ERSAB and the local authorities internal learning and skills team. To enable development in this area, the ERSAB and ASCH have collaborated with Hull City Council’s safeguarding adults board and Adult Services to review and renew the VARM procedure to contemporise the approach and develop a more seamless and accessible procedure in this geographical area. The VARM training is therefore currently under review and will be relaunched following the completion of this work to ensure and enable an effective roll out of the new procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be considered by the service at our practice development board which is chaired by our Head of Service for Safeguarding and Quality Assurance.