Dear Ms Kearsley Re: William OLIVER (Deceased) Thank you for your correspondence of 12 September 2019 regarding regulation 28 concerning the inquest of the above named patient, Please accept our apologies for the in responding to you As always, am grateful to you for highlighting your concerns and for providing me with an opportunity to respond: As per your regulation 28 report to prevent future deaths, will respond to the point you have raised: Iuraround Times at Greater _Manchester_Hospitals Another contributing factor to the decreased availability of ambulances on the 31*t October 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites: Whilst all hospitals were the turnaround times at Manchester Royal Infirmary; North Manchester General hospital, Royal Oldham; Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour: In total from the commencement of the night shift on the 34st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. evidence from NWAS did not suggest this was significantly different to other nights or uncommon The Trust recognises that our average turnaround time for ambulances has not yet achieved the required average of 30 minutes with none waiting over hour. This target is measured weekly by Greater Manchester Urgent and Emergency Care Hub and is published for all Greater Manchester trusts. Stockport NHS Foundation Trust recorded an average turnaround for ambulances of 33 minutes for the period 28" October 2019 to 3r4 November 2019 The following actions have been put in to place to ensure ambulance crews can be released from the hospital: The trust uses an electronic patient tracking system in the emergency department which enables the organisation to have a live display of the progress of patients through the department There is also a screen displaying ambulance arrival times; number of inbound ambulances and ambulance turn around times. Both these screens are monitored by the departments shift coordinator who directs the workflow accordingly. This information is also available at all times to the hospital control room, managers on call and senior executive team

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The trust holds three bed meetings each chaired and attended by senior trust staff: One of the metrics reviewed as part of this meeting is the current live turnaround time for ambulances from our Emergency Department. We have also purchased 24 additional trolleys for the Emergency Department to ensure equipment availability to transfer patients from the ambulance trolley's to enable crews to be released in a timely manner. On days of high demand the trust works closely with Greater Manchester Urgent and Emergency Care Hub and can have Ambulance Liaison Officers on site to ensure that any delays in releasing crews are dealt with promptly_ Patients referred to the hospital by their GP who attend via ambulance can be streamed directly to our Ambulatory Care Unit, which by-passes an Emergency Department admission: On October 25th 2019 Stockport NHS Foundation Trust was invited to join a Phase 2 NWAS ambulance handover collaborative project which will be looking at shared learning from across the region The trust is delighted to have been invited to take part, and have ensured our engagement by enabling staff from our Emergency Department operational and administrative teams to engage in this collaborative hope that this response addresses your concerns and provides you with the assurance that the Trust is committed to improving the quality of care'we give to all our patients. Please do not hesitate to contact me if you have any further questions regarding this matter.

Dear Ms Kearsley, Re: Response to Regulation 28 report in relation to William Oliver We are responding to the matters of concern raised following the death of William Oliver at his home address of 42 Earles Lodge, Albert Street; Failsworth, on 1st November 2018. The Ambulance Commissioning Team_ hosted at Blackpool CCG, is responsible for commissioning North West Ambulance Service (NWAS) on behalf of the 31 North West CCGs Coroners Concerns: Meal Break Policy and Shift Rostering During the course of the Inquest the Court heard evidence as to the demand experienced by NWAS during the night of 31st October-1st November. One of the reasons for difficulties in allocating resources was directly attributed to the meal break policy. In short, the issue being that each crew has to take a 30 minutes meal break within their meal break window: This has been highlighted in other serious incident investigations. In this case there was a significant reduction in the number of vehicles able to be allocated during the time Mr Oliver had contacted NWAS The court heard that this policy has been under review, but that no changes had been implemented: Ambulance Commissioning Team, Blackpool CCG response: As part of the NHS Standard Contract 2019/20 Service Development Improvement Plan Blackpool CCG has emphasised the importance of a Roster Review and have included the Roster Review in commissioner requirements to support and gain assurance from NWAS in its implementation; The roster review will use detailed demand profiling data to align the entire workforce to meet the expected service demand and will be reviewed on an annual basis. As part of these changes the meal break policy will be reviewed to ensure that it does not compromise the effectiveness of this workforce profiling: Implementation in Greater Manchester is planned for January 2020. Blackpool CCG Chairman Roy Fisher Chief Clinical Officer Dr Amanda Doyle OBE Fylde and Wyre CCG Chair - Mary Dowling Way Way yet

2 Times at Greater Manchester Hospitals Another contributing factor to the decreased availability of ambulances on the 31st October-1st November was the turnaround times at hospitals in the Greater Manchester area. Whilst hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester General, Royal Oldham , Salford Royal and Stepping Hill Hospitals were all particularly higher than anticipated with numerous ambulances delayed for over an hour Ambulance Commissioning Team, Blackpool CCG response: Recognising that handover and turnaround performance is a whole system responsibility there has been significant system-wide focus on improvement: It formed part of the NWAS Performance Improvement Plan and in 2018 the North West Handover Stakeholder Engagement group was established_ A collaborative programme called 'Every Minute Matters' , was undertaken over winter 2018/19 with six identified hospital sites to deliver sustained 30 minute performance for handover (the national target): The sites were chosen because they had challenged performance and collectively represented a significant proportion of ambulance arrivals due to their size , so improvements at these sites would have a disproportionate impact on the whole North West The programme's aim was to reduce hospital handover times by using improvement methodology. All hospitals participated in learning workshops and undertook rapid tests of change: All six sites focused on understanding their processes and data and using measurement to drive improvement: The collaborative approach has fostered sharing of practice but also friendly competition between the sites, with reduction in handover times being achieved. One Greater Manchester Hospital was included in this cohort: A further eight hospitals have started this programme at the end of October 2019 including two further Greater Manchester hospitals. The intention is for this programme to be implemented at all North West Emergency Departments, including Greater Manchester hospitals, to improve handover times and therefore increase the availability of ambulances to respond_ The stakeholder group has recently been superseded by a North West Handover Improvement Board, cO- chaired by the NHSEI Director of Improvement and the NWAS Chief Executive. This Board will provide leadership and direction to system wide handover improvement work, particularly within A&E Delivery Boards_ We would like to thank you for drawing attention to these important matters and providing further impetus for system-level change that will reduce the future risk to patients. We hope that our response has provided sufficient assurance that these themes had been identified and that a programme of work is in place to address them. Should you require any further information please do not hesitate to contact us_

Dear Ms Kearsley,

Inquest touching the death of William Oliver

I write in relation to the Regulation 28 report that you issued at the conclusion of the inquest touching the death of William Oliver.

I know that you will share this response with Mr Oliver’s family and I firstly want to express my sincere condolences to his family.

The Trust is committed to providing the right care, at the right time and in the right place but I fully acknowledge that on this occasion, the Trust did not provide Mr Oliver with an ambulance as quickly as it should have done and I am extremely sorry for that. The Trust takes all adverse events very seriously and the Trust undertook a thorough internal review into the attendance on Mr Oliver.

Through the Regulation 28 report you have requested that NWAS consider your matters of concern and have suggested that action is taken to prevent future deaths. By this letter, I will address those concerns as far as I am able to do so.

1. Meal Break Policy and Shift rostering

The Trust needs to find a balance between maintaining resource availability in order to respond to incidents whilst at the same time complying with health and safety legislation and ensuring the crews are appropriately dined and rested in order to deliver a high standard of care.

Roster review

Through the written and oral evidence which was before you during the inquest, you are aware that the Trust has been working in partnership with external consultants and is undertaking a wholesale review of the Trust’s shift and roster arrangements. The roster review has been ongoing since May 2019 and has required consultation with both the Trust’s employees and Unions since the changes which the review will effect are significant and will substantially change the operational working arrangements by staggering shift start times and shift lengths.

- 2 - The roster review allows the Trust to maximise the availability and use of existing resources, identify where investment is best placed and also lead to a redistribution of its fleet so that vehicles are located in the areas where they are needed most.

Together with our lead commissioners, the Trust is committed to completing the roster review and particularly the use of detailed demand profiling to align the workforce to meet the expected levels of demand.

The Trust plans to commence the implementation of the revised shift start times/lengths, within Greater Manchester, in February 2020.

Pilot: Meal Break Policy

In addition to the roster review, in July 2019 following consultation with our commissioners, the Trust commenced an executive lead review of the meal break policy which has seen the formulation of a focus group encompassing representatives from HR, operations and the medical directorate.

The focus group has reviewed the current working practices and the control room guidance linked to meal break management. Within the Emergency Operations Centre (EOC) the task of managing meal breaks falls to the dispatchers who, during periods of high demand, naturally focus on the management of incidents and ambulance dispatch which, consequently, leads to crews being dined outside of the meal break window.

Through the work of the focus group, a pilot has been devised which will take the management of the meal break away from the dispatcher and also see a mandatory staggered stand down of resources throughout the meal break window.

The pilot has received approval from the Trust’s Executive Leadership Committee and is already being trialed from within the Cheshire and Mersey EOC. The intention is that through this mandatory stand down, the number of crews being dined outside of the meal break window will be reduced to the lowest possible level and maintain resource availability.

Additional Investment

Aside from the work highlighted above, following the demand and capability assessment that was referred to in the Trust’s written evidence, the Trust has received significant additional investment from its commissioners. As a result of that investment, the Trust will be putting an additional 250 paramedics into the service between now and March 2020.

I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed you concerns by this response. If it assists, the Trust will be more than willing to provide you with an update at the conclusion of the pilot.

If you require any further information or clarification, please do not hesitate to contact me or the Trust’s Head of Legal Services.

From Edward Argar MP Minister of State for Health Department of Health & 39 Victoria Street London Social Care SW1H OEU 020 7210 4850 Our Ref: PFD-1190331 Ms Joanne Kearsley HM Senior Coroner, North Manchester Coroner's Service Phoenix Centre LICpl Stephen Shaw MC Way (formerly Church Street) Heywood OL1O ILR 28 January 2020 J-mKdj' Thank you for your correspondence of 12 September 2019 to Matt Hancock about the death of Mr William Oliver. am responding as Minister with responsibility for urgent and emergency care and am grateful for the additional time in which to do so. Firstly, would Iike to say how saddened was t0 read of the circumstances of Mr Oliver' s death and extend my sympathies to his family and loved ones. It is important that we look to make improvements where we can to ensure safe and high quality healthcare services: am informed that the North West Ambulance Service NHS Trust has acknowledged that on this occasion, it did not provide the right care, as quickly as it should have done. In preparing this response, Departmental officials have taken advice from the Association of Ambulance Chief Executives (AACE) and NHS England and NHS Improvement: On the matter of meal breaks and shift rostering, paramedic meal breaks and shift patter arrangements are operational matters for individual ambulance trusts and there is no national ambulance meal break policy. Meal break requirements are set out in employment law (including the Working Time Directive) and NHS ambulance trusts develop their own policies to ensure compliance with the law. am advised that all ambulance services are aware of the need to stagger meal breaks as much as possible and to regularly review rostering systems. When on meal breaks, staff are effectively off duty and are free to leave their working environment and use the time as they wish: However; ambulance trusts have arrangements in place to enable staff to elect that; on a voluntary basis, they are willing to be disturbed during breaks to attend life- threatening incidents:

am assured that all ambulance trusts are aware of their responsibilities in this area and regularly review rostering arrangements to ensure they are robust and optimised to meet current demand patters: am advised that following a review, the North West Ambulance Service is looking to introduce new shift rostering and meal break arrangements to better meet resource demands and has benefitted from increased investment commissioners for an additional 250 paramedics: In relation to ambulance handover delays, we are clear that patient handovers must take place within agreed timeframes. NHS England and NHS Improvement are taking ajoint approach to improve performance , including: The identification of regional leads for handover performance, holding NHS providers to account for improved performance; Emergency Care Improvement Teams supporting the most challenged acute trusts with identified handover delay issues to improve performance; The issuing of revised, detailed hospital handover guidelines, focussing responsibility on the wider system t0 address handover delays, including clear escalation procedures; and, Improved monitoring and reporting of patient handover delays. The NHS Standard Contract' stipulates that patient handovers need to be completed efficiently within 15 minutes to allow ambulance resources to be returned to service quickly (ambulance crews then have a further 15 minutes to make their ambulance ready to respond to new calls): The Department has made the AACE aware of the concerns in your report; The AACE acts as a national cO-ordinating voice on issues of policy and practice for ambulance trusts and am advised that the AACE takes seriously the learning that can be gained from Prevention of Future Deaths reports. The AACE has mechanisms in place to bring matters of concern to the attention of ambulance trusts in England and to promote the development of good practice Finally, we know that there is high demand for ambulance services Including calls transferred NHS 111, ambulance services deal with more than 11 million 999 calls every year: However we are significant action to improve ambulance services at a regional and national level. Nationally; we have implemented an improved ambulance performance framework across all ambulance trusts in England that prioritises responses to the sickest patients, while helping to reduce long waits and ensuring patients receive the most appropriate response for their condition: This includes reducing unnecessary journeys to hospital by safely treating at scene where clinically appropriate which in turn increases the availability of ambulances to respond to other incidents https: WWW _ englandnhs uklwp-contentuploads/2019/03 8-NHS Standard-Contract-Technical-Guidance-1920-vLpdf from from taking

hope this response is helpful. am grateful to you for bringing these matters to my attention: 2-~ FJ_ 0 EDWARD ARGAR MP