Yorkshire Ambulance Service
NHS / Health Body
Action Planned
Yorkshire Ambulance Service is undertaking a Patient Safety Investigation and will review the initial call, 'fit to sit' decisions, the role of the HALO, and transport to specialist hospital, and is working to introduce equipment risk assessment and reduce number of incidents with mobility equipment. (AI summary)
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Dear Ma’am, Re: Inquest touching the death of Susan Shipley I write on behalf of Yorkshire Ambulance Service NHS Trust (YAS) and in response to the Regulation 28 report on this matter, issued on 28 October 2024. I am aware of the circumstances of Mrs Shipley’s sad death, and I offer my sincere condolences to her family. I also take this opportunity to say how sorry I am that Mrs Shipley sustained a fall whilst in our care, and that injuries sustained from the fall contributed to her deterioration. I have been appraised of the findings of your inquest, in particular that an initial ‘fit to sit’ decision was incorrect and led to inappropriate use of a hospital wheelchair when transferring Mrs Shipley. This is reflected in your matters of concern, which are: “a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above; b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear; c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption; d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.” To address these concerns, I have taken advice from YAS’s Executive Medical Director, who informs me as follows: The current ‘fit to sit’ process “‘Fit to Sit’ is an initiative used in the NHS to assess patients in emergency departments or urgent care settings. If satisfied it means that a patient is considered stable enough to wait for treatment without the need for a hospital bed or stretcher and can instead remain seated in a chair or other comfortable seating. This approach aims to streamline the flow of patients and prioritises the use of beds for those who truly need them. The approach promotes greater independence as sitting in a chair can feel more natural and empowering to patients, as they retain more mobility, can engage with staff or family members more comfortably, and generally feel less like they are “confined” to a bed. YAS does not have a specific ‘fit to sit’ policy, instead it uses the self-handover process, the flowchart for which I attach as Appendix 1. This has inclusion and exclusion criteria outlining which patients are appropriate for this process. It includes a National Early Warning Score 2 of above 3 as a potential exclusion. This process feeds into York and Scarborough Teaching Hospitals ‘fit to sit criteria’, attached as Appendix 2. Patients who are assessed as meeting the YAS self-handover criteria are deemed as fit to sit in the hospital flowchart. Patients who do not meet the YAS self-handover criteria are assessed by a receiving clinician at the Emergency Department, be that a nurse, doctor, or Advanced Clinical practitioner, and then re-assessed for suitability in this regard. Decisions on ‘fit to sit’ The decision to classify a patient as "fit to sit" is ultimately based on the clinical judgment of healthcare professionals. Their experience and expertise are essential in assessing each patient’s individual condition, stability, and care needs. Clinical judgment allows them to decide whether a patient can be safely monitored while seated or requires a bed. Experienced healthcare professionals can detect subtle signs that might indicate underlying instability or time critical presentations, even if initial vital signs appear normal. Assessment in this regard should not end with the paramedic’s initial assessment. The patient should be continuously reassessed throughout the handover process and beyond by the receiving department for their suitability as to remain a ‘fit to sit’ patient and monitored for any signs of change in their condition. This proactive monitoring helps ensure that patients receive appropriate care if their status shifts unexpectedly. Clinical staff must weigh the availability of beds and resources against patient safety, ensuring that the most critical patients receive immediate care. While guidelines and protocols help inform "fit to sit" decisions, clinical judgment lies at the core of this approach. Paramedics are degree educated, registered healthcare professionals who apply their experience, knowledge, and intuition to make decisions that
maximise patient safety and ensure efficient use of resources in high-demand settings. Similarly, the wider clinical workforce outside of paramedics should be supported by the receiving departments in this regard. Actions in response to Regulation 28 report YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff. This policy will emphasise the need for documenting the reasoning behind the clinical decision on the electronic Patient Record, ensuring it is visible to subsequent clinicians assessing the patient. It will also mandate that the ‘fit to sit’ decision needs to be reviewed, and the patient be reassessed by all subsequently attending ambulance staff taking responsibility for the patient. The standards of documentation within ambulance patient care records remain a continued area of focus at regional investment days, with oversight from the regional advanced paramedic clinical leads. Additional actions This very sad event contributed to the launch of a collaborative clinical safety group attended by operational and clinical leads from the ambulance service and York and Scarborough Hospitals. This meeting reviews cases such as this with the aim to avoid future patient harm caused by handover delays and ambulance queues. Mrs Shipley’s care has been discussed within this forum and an action taken to encourage ambulance crews to seek to override a divert when presented with a patient requiring a specialist service available at the hospital that is on divert. Additionally, a case-based discussion has been held with the attending clinicians at the first ambulance call which led to the patient being transported to Scarborough Hospital. This was led by our Advanced Paramedic Clinical Lead and involved critically reflecting to enable points for consideration from a safety perspective to be highlighted. There is planned feedback for the HALO. The second ambulance crew responsible with transporting the patient from Scarbrough to York participated in an After-Action Review, attended by system partners and key stakeholders. This again enabled critical reflection of the events and identified systemwide learning. As a result of this discussion, a notice has been issued to all patient facing ambulance teams in Humber and North Yorkshire by the area’s Consultant Paramedic regarding the correct use of portering chairs and the need for continued dynamic risk assessment when transporting patients between ambulances and the receiving
departments. I understand that the work that is being undertaken by YAS Health and Safety team on use of appropriate patient transport aids was outlined at the inquest. Following the conclusion of your inquest, the complexities and potential for learning was discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive Medical Director. From this he commissioned a full investigation into the care of Mrs Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” has been initiated, which focuses on identifying learning responses to improve our service to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to participate in this investigation. Investigations of this nature can take some time to complete as there is a breadth of information to process, as a number of other patient experiences will be reviewed and evaluated so appropriate learning can be identified to inform change for the future and better improve our practices. The timescale for the completion of this investigation and preparation of the report will be February/March 2025. Although not yet completed, the investigation is well under way, and I can share the following. YAS had identified that Moving and Handling was a local priority theme upon introduction of the Patient Safety Incident Response Framework (PSIRF). A dedicated Moving and Handling focus group meets regularly to discuss incidents involving this theme. This group is facilitated by our Health and Safety Manager, supported by our Moving and Handling Lead and Patient Transport Service Quality Lead. This group ensures a collaborative and clear focus on providing the guidance and support to staff in providing safe care to patients. One of the main areas of focus is the transfer of patients to hospital care, specifically the use of the hospital portering wheelchairs. In October 2024, following a number of pieces of research work by our Moving and Handling Lead, a hospital portering wheelchair equipment risk assessment was introduced which identified tasks at the highest risk, namely transporting patients from vehicle to hospital over uneven ground without use of a lap belt, and using a wheelchair for access or egress to/from ramp access ambulance vehicles. Early indications highlight that the introduction of the risk assessment has helped identify specific actions that are required to reduce the risks. This work remains ongoing which will allow us to draw conclusions on its effectiveness in terms of reduction of number of patient safety incidents specific to moving and handling. In addition, the investigation will review the entire timeline and therefore also include the nature of the initial call, the management and impact of the divert, points for ‘fit to sit’ decisions, the role of the HALO, and transport to the specialist hospital. A detailed, comprehensive Patient Safety Investigation incident report will be produced and will be made available to the family and relevant stakeholders to view.
I was so sorry to hear of the death of Mrs Shipley in these circumstances. I do hope this letter provides you and her family with some assurance that we have put in place, and continue to explore, measures to ensure greater safety for our patients. My thoughts remain with Mrs Shipley’s family.
e) The potential risk of death to others in the event of a recurrence of any of the above.” To address these concerns, I have taken advice from YAS’s Executive Medical Director, who informs me as follows: The current ‘fit to sit’ process “‘Fit to Sit’ is an initiative used in the NHS to assess patients in emergency departments or urgent care settings. If satisfied it means that a patient is considered stable enough to wait for treatment without the need for a hospital bed or stretcher and can instead remain seated in a chair or other comfortable seating. This approach aims to streamline the flow of patients and prioritises the use of beds for those who truly need them. The approach promotes greater independence as sitting in a chair can feel more natural and empowering to patients, as they retain more mobility, can engage with staff or family members more comfortably, and generally feel less like they are “confined” to a bed. YAS does not have a specific ‘fit to sit’ policy, instead it uses the self-handover process, the flowchart for which I attach as Appendix 1. This has inclusion and exclusion criteria outlining which patients are appropriate for this process. It includes a National Early Warning Score 2 of above 3 as a potential exclusion. This process feeds into York and Scarborough Teaching Hospitals ‘fit to sit criteria’, attached as Appendix 2. Patients who are assessed as meeting the YAS self-handover criteria are deemed as fit to sit in the hospital flowchart. Patients who do not meet the YAS self-handover criteria are assessed by a receiving clinician at the Emergency Department, be that a nurse, doctor, or Advanced Clinical practitioner, and then re-assessed for suitability in this regard. Decisions on ‘fit to sit’ The decision to classify a patient as "fit to sit" is ultimately based on the clinical judgment of healthcare professionals. Their experience and expertise are essential in assessing each patient’s individual condition, stability, and care needs. Clinical judgment allows them to decide whether a patient can be safely monitored while seated or requires a bed. Experienced healthcare professionals can detect subtle signs that might indicate underlying instability or time critical presentations, even if initial vital signs appear normal. Assessment in this regard should not end with the paramedic’s initial assessment. The patient should be continuously reassessed throughout the handover process and beyond by the receiving department for their suitability as to remain a ‘fit to sit’ patient and monitored for any signs of change in their condition. This proactive monitoring helps ensure that patients receive appropriate care if their status shifts unexpectedly. Clinical staff must weigh the availability of beds and resources against patient safety, ensuring that the most critical patients receive immediate care. While guidelines and protocols help inform "fit to sit" decisions, clinical judgment lies at the core of this approach. Paramedics are degree educated, registered healthcare professionals who apply their experience, knowledge, and intuition to make decisions that
maximise patient safety and ensure efficient use of resources in high-demand settings. Similarly, the wider clinical workforce outside of paramedics should be supported by the receiving departments in this regard. Actions in response to Regulation 28 report YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff. This policy will emphasise the need for documenting the reasoning behind the clinical decision on the electronic Patient Record, ensuring it is visible to subsequent clinicians assessing the patient. It will also mandate that the ‘fit to sit’ decision needs to be reviewed, and the patient be reassessed by all subsequently attending ambulance staff taking responsibility for the patient. The standards of documentation within ambulance patient care records remain a continued area of focus at regional investment days, with oversight from the regional advanced paramedic clinical leads. Additional actions This very sad event contributed to the launch of a collaborative clinical safety group attended by operational and clinical leads from the ambulance service and York and Scarborough Hospitals. This meeting reviews cases such as this with the aim to avoid future patient harm caused by handover delays and ambulance queues. Mrs Shipley’s care has been discussed within this forum and an action taken to encourage ambulance crews to seek to override a divert when presented with a patient requiring a specialist service available at the hospital that is on divert. Additionally, a case-based discussion has been held with the attending clinicians at the first ambulance call which led to the patient being transported to Scarborough Hospital. This was led by our Advanced Paramedic Clinical Lead and involved critically reflecting to enable points for consideration from a safety perspective to be highlighted. There is planned feedback for the HALO. The second ambulance crew responsible with transporting the patient from Scarbrough to York participated in an After-Action Review, attended by system partners and key stakeholders. This again enabled critical reflection of the events and identified systemwide learning. As a result of this discussion, a notice has been issued to all patient facing ambulance teams in Humber and North Yorkshire by the area’s Consultant Paramedic regarding the correct use of portering chairs and the need for continued dynamic risk assessment when transporting patients between ambulances and the receiving
departments. I understand that the work that is being undertaken by YAS Health and Safety team on use of appropriate patient transport aids was outlined at the inquest. Following the conclusion of your inquest, the complexities and potential for learning was discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive Medical Director. From this he commissioned a full investigation into the care of Mrs Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” has been initiated, which focuses on identifying learning responses to improve our service to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to participate in this investigation. Investigations of this nature can take some time to complete as there is a breadth of information to process, as a number of other patient experiences will be reviewed and evaluated so appropriate learning can be identified to inform change for the future and better improve our practices. The timescale for the completion of this investigation and preparation of the report will be February/March 2025. Although not yet completed, the investigation is well under way, and I can share the following. YAS had identified that Moving and Handling was a local priority theme upon introduction of the Patient Safety Incident Response Framework (PSIRF). A dedicated Moving and Handling focus group meets regularly to discuss incidents involving this theme. This group is facilitated by our Health and Safety Manager, supported by our Moving and Handling Lead and Patient Transport Service Quality Lead. This group ensures a collaborative and clear focus on providing the guidance and support to staff in providing safe care to patients. One of the main areas of focus is the transfer of patients to hospital care, specifically the use of the hospital portering wheelchairs. In October 2024, following a number of pieces of research work by our Moving and Handling Lead, a hospital portering wheelchair equipment risk assessment was introduced which identified tasks at the highest risk, namely transporting patients from vehicle to hospital over uneven ground without use of a lap belt, and using a wheelchair for access or egress to/from ramp access ambulance vehicles. Early indications highlight that the introduction of the risk assessment has helped identify specific actions that are required to reduce the risks. This work remains ongoing which will allow us to draw conclusions on its effectiveness in terms of reduction of number of patient safety incidents specific to moving and handling. In addition, the investigation will review the entire timeline and therefore also include the nature of the initial call, the management and impact of the divert, points for ‘fit to sit’ decisions, the role of the HALO, and transport to the specialist hospital. A detailed, comprehensive Patient Safety Investigation incident report will be produced and will be made available to the family and relevant stakeholders to view.
I was so sorry to hear of the death of Mrs Shipley in these circumstances. I do hope this letter provides you and her family with some assurance that we have put in place, and continue to explore, measures to ensure greater safety for our patients. My thoughts remain with Mrs Shipley’s family.