Colin Wiles

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.