Dear Ms Murphy, Re: Regulation 28 Report to Prevent Future Deaths – Shaun Mansell, who died on 6 July 2021 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 November 2021 concerning the death of Shaun Mansell on 6 July 2021. Firstly, I would like to express my deep condolences to Mr Mansell’s family. I note the inquest earlier this year concluded Shaun Mansell’s death was a result of natural causes (acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism). Following the inquest, you raised concerns in your Report to NHS England regarding excessive delays in handing over patients at hospital which impacts on ambulances getting to patients. I can confirm that national policy has set out that handovers should take no more than 15 minutes, ensuring patients receive necessary emergency care and allowing ambulances to get back on the road responding to patients in the community. We recognise however that hospital handover delays are a significant challenge for ambulance services and acute trusts both regionally and nationally and tackling this is a high priority for NHS England and NHS Improvement. The NHS Long Term Plan made a commitment to work with ambulance services to eliminate hospital handover delays. Ambulance services continue to, where appropriate and safe to do so, use alternative approaches to taking patients to Emergency Departments (EDs) and therefore reduce front door congestion, including increasing use of ‘See and Treat’, and conveying patients to non-ED settings such as urgent treatment centres. Handover delays can be linked to patient flow issues, and NHS England and NHS Improvement are also supporting systems to improve hospital flow through reducing length of stay and supporting timely discharge. National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 23 December 2021

On 13 December, as part of “Preparing the NHS for the potential impact of the Omicron variant and other winter pressures”, NHS England and NHS Improvement wrote to systems to reiterate earlier communication regarding the need to eliminate ambulance handover delays to ensure vehicles and paramedic crews are available to respond to urgent 999 calls. A range of measures, which have demonstrated benefits in addressing handover delays, were previously shared with all systems. I can also confirm that additional funding was made available for winter 2021/22 to support investment in Hospital Ambulance Liaison Officer staff to support handover of care.

Thank you for bringing this important patient safety issue to my attention and I do hope the above information helps to inform you of the work and steps being taken by NHS England and Improvement to tackle it.

Please do not hesitate to contact me should you need any further information.

Dear Ms Murphy Inquest Touching the Death of Shaun Mansell Thank you for your letter dated 16 November 2021, in relation to the late Shaun Mansell who I note, very sadly, died as a result of natural causes at home; I extend my sincere condolences to Mr Mansell’s family. Whist I am pleased to provide the following response to the concerns that you raised at the inquest touching the death of Mr Mansell, I need to express how perplexed I was at receiving the Regulation 28 in the first instance, given that the University Hospitals of North Midlands NHS Trust (UHNM) never treated this gentleman; I also understand that there was no one from the Trust in attendance at the inquest. Nevertheless, you raised the following matter of concern to be addressed by this Trust only:
1. There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service Serious Incident Report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands I understand that on the night in question, ambulances were delayed at UHNM as they were at most hospitals up and down the country, which is something that all of us in the wider economy work very hard to avoid. However, I cannot understand why UHNM would be singled out in this way, in relation to this incident, when the reason for ambulance delays at hospitals are multifactorial and rely on many system partners and organisations, including the ambulance service, to resolve. For example, delays can occur for the following reasons to name but a few:
1. The acute Trust (wherever that may be) has limited or no bed capacity - this can be because it is overwhelmed by the number of emergency patients and/or because too many beds are full with patients that do not need to be in hospital and are medically fit for discharge. It is the responsibility of the Local Authority Social Care system and our system Community providers to deliver such ‘out of hospital’ services however, because of their own staffing and capacity constraints they are not able to take new patients. Therefore, both patients and the incumbent risks remain with the acute provider. The consequence of this is lack of flow through the hospital generally which then impacts on Emergency Departments (ED) throughout the country; they become congested and ambulances have to wait to off load new patients.
2. Approximately 30% of patients who attend ED do not need the services of the ED:

a. An increasing number of these patients arrive because they cannot get an appointment with their GP because GPs are having their own workforce crisis and do not have the capacity or resource to see the ever increasing demand in Primary Care.

b. There is a role for Public Health and all health and care providers to support the population in making better and more appropriate choices for health care such as self-care, NHS 111, Pharmacists etc. Reducing demand in ED by 30% would be significant and would probably resolve all flow issues and therefore negate the need for any ambulances to wait unnecessarily.

c. A number of patients brought to hospital by ambulance do not need to come to an acute provider. There are other services available to prevent a conveyance to hospital and these alternatives, such as the Community Rapid Intervention Service (CRIS) and the Local Authority Falls Service, should be used instead. This would reduce the number of ambulances coming to ED and therefore the waiting times in the ED. As a result of patients attending EDs who do not need to, the department becomes congested and again ambulances end up waiting as a result.

3. Patients with Mental Health illnesses spend too long in EDs waiting for mental health assessments which are provided by our mental health providers. Again if these patients did not have to wait as long as they did, the ED would be less congested and flow of ambulances would be improved.

Whilst my aim is not minimise the outcome for Mr Mansell in this particular case, I do hope the above gives a few examples of how this is a whole system issue, involving every provider of health and social care. I also hope from the examples provided above you can see why, as just one provider, I was dismayed at receiving the Regulation 28 when in reality, if a Regulation 28 was to be sent beyond West Midlands Ambulance Service, it should have been sent to all providers; Primary Care, Mental Health, Community Provision and Social Care.

Having said that, UHNM takes its share of responsibility very seriously and there are actions that we have taken both as an organisation and with system providers to make a difference. I have outlined below what the Trust has done in an attempt to reduce the number of ambulances waiting.

1. The placing of 111 Kiosks at both RSUH and County EDs to allow alternative pathways out of the ED, for patients to take.

2. A Nurse Navigator at the front door of ED – this is to support redirection to alternative places of care for ambulatory non acute patients.

3. The use of an innovative IT system called ‘GP Connect’ to allow direct communication to hospital teams from primary care which will reduce the number of patients GPs need to send to ED.

4. We are working with our partners in the CCG and the Vocare Urgent Care Centre (UCC) to enhance Urgent Care Centre pathways; this is to reduce the demand through the ED by taking more patients through the UCC.

5. UHNM undertakes ‘Length of Stay’ reviews for all long stay patients to ensure that they are discharged home as soon as optimized, whilst also recognising that this requires the support of our out of hospital providers of care as outlined above.

6. West Midlands Ambulance Service (WMAS) now have access to our Same Day Acute Pathways and can use these instead of bringing patients through ED.

7. We have separate hot and cold ambulance arrival areas to segregate COVID and non COVID ambulance arrivals which will continue over winter.

8. We are working closely with social care to increase access to the domiciliary care market and placements for those patients that do not need to come into hospital. The NHS has also given Social Care over £4 million of funding to increase social care provision although we are yet to see the benefits of this.

9. As our Community Rapid Intervention Service (CRIS) is not always appropriately accessed and utilised we now position members of the CRIS team inside our ED to turn around inappropriate conveyances and attendances to the ED.

10. The CRIS is working with WMAS on access to the Ambulance Service Information System so that they can review the patients waiting and remove these directly from their list, ultimately reducing the number of ambulances having to attend UHNM.

11. Over the last few months, we have seen a significant increase in the number of patients in our hospital beds that do not need to be there. We are therefore working hard with NHS and Social Care colleagues to reduce this number of patients which will in turn allow better flow of patients out of ED, reduce ED congestions and thus speed up the turnaround of ambulances.

12. When Primary Care staffing is available we have a GP working on the ED front door to see patients who do not require the services of an ED.

In addition to those points above and to ensure a safe and consistent approach in managing ambulance arrivals when there is a necessity to hold WMAS crew and patients on ambulances (due to capacity issues in the ED) a Standard Operating Procedure (SOP) was developed in February 2021; the staff in the ED follow this process on a daily basis.

This SOP includes actions such as:  Prioritising patients by clinical need  Ensuring that all patients have their observations taken  Review by a Clinician whilst on the ambulance and  The relocation of space in the department, as required, to allow the sickest patients to be taken into the appropriate area of ED.

As an organisation, we absolutely recognise the challenges that ‘ambulance holds’ have on both the ambulance service and our patients out in the community and we are committed to improving the current performance. However, we hope you can see from the above that an equal number of actions are required by other health and care organisations and without which, UHNM alone will not be able to make the difference required to reduce ambulance delays.

This is a national issue which as you can see, requires a system response and therefore a Regulation 28 served to UHNM will not be able to provide you with the assurance you require. However, I trust this response provides some reassurance that the Staffordshire and Stoke-on-Trent health and care system is taking action to minimise such delays.

I trust that the above information provides you with some explanation as to the national difficulties and our local responses to these. However, please do not hesitate to contact me should you require any further information.