Sophie Hindmarsh

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Sophie Hindmarsh who died on 17 August 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 April 2024 concerning the death of Sophie Hindmarsh on 17 August 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sophie’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Sophie’s care have been listened to and reflected upon. 

Your Report raised the concern over significant delay in offloading patients at hospitals which tied up ambulance resource and impacted the ambulance service’s ability to respond to emergency calls.

NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlined key actions to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms), alongside broader system actions to improving flow through hospitals and reducing handover delays, speeding up discharges from hospitals, expanding new services in the community, all of which should help ambulance crews to get back on the road to the next waiting patient more rapidly.

Whilst ambulance response times have not returned to pre-pandemic levels, there have been improvements in ambulance response time targets nationally during 2023/24. The 2023/24 year-end Category 2 Mean was 36 minutes 23 seconds which is 13 minutes 37 seconds lower than 2022/23. For 2024/25, the Delivery Plan continues to focus on the improvement of ambulance Category 2 response times, with ambulance services expected to maintain the increases in capacity achieved throughout 2023/24, alongside the continued development of alternative referral pathways (e.g. urgent community response) to ensure that patients receive timely and high-quality care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 June 2024

Handover delays have reduced nationally over 2023/24 but still present a significant issue to achieving increases in ambulance service capacity, particularly within certain geographical areas. Targeted handover improvement work (for the acute trusts with the highest amount of handover delays) has been undertaken throughout 2023/24. Hospitals have worked collaboratively with ambulance services and the NHS England Regional teams to ensure patients are able to be handed over as quickly as possible. This includes utilising Fit 2 Sit for patients who can safely sit on a chair (rather than a hospital trolley), and direct referrals to Same Day Emergency Care and Urgent Treatment Centres. NHS England has also engaged with West Yorkshire Integrated Care Board (ICB), who we note will also be responding to your Report and we have been asked to be sighted on their final response to you. NHS England are advised that there has been an improved trajectory of ambulance handovers within South Yorkshire since 2022, and that measures to drive improvements include:
• Joint escalation processes within South Yorkshire
• Investment in crews, fleet and the Emergency Operation Centre (EOC)
• EOC clinical workforce enhancements to support both calls and crews attending in the community, to promote appropriate alternative care pathways.

In June 2023, NHS England published the NHS Long Term Workforce Plan, which sets out how we will grow, train, retain and reform the NHS workforce over the next fifteen years to help meet the growing demands on our services. It is underpinned by the biggest recruitment drive in NHS history and includes an expansion of medical specialty training for urgent and acute care.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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 Berry,

Thank you for your letter of 29 April 2024 in relation to the Regulation 28 report to prevent future deaths, following the inquest into the death of Sophie Hindmarsh. This was issued to:
1. The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU
2. The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT I would like to start by offering condolences to the family of Sophie on behalf of the Yorkshire Ambulance Service, NHS West Yorkshire Integrated Care Board as the lead commissioner, and our partners across the region. I am sorry for their loss and the circumstances surrounding the death of Sophie. I hope this letter provides reassurance of our joint commitment to delivering services that meet the needs of the population within Yorkshire and the Humber, and that the actions we have taken reflect the lessons learnt and the investment and changes made. You asked for a response from the NHS West Yorkshire Integrated Care Board (WYICB) as the lead commissioner of services from the Yorkshire Ambulance Service (YAS) regarding the following areas of identified concern, as well as the actions and timelines that are being taken with our system partners to put in place improvements. My response covers the following:
• The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.

• There was a significant delay in handing over patients at hospitals which meant they were unable to respond to emergency calls. Background During the financial year 2022/23 the ambulance services in the country were experiencing increased pressure, ultimately resulting in extended response times that did not meet national standards. During this period the average response time for Category 2 calls nationally (based on the mean) extended to 50 minutes and 0 seconds, with the July 2022 position being worse at 58 minutes 53 seconds. The overall systemic pressure felt across the country impacted YAS, which had average Category 2 response times of 42 minutes and 4 seconds across the year and 44 minutes and 44 seconds in July 2022. Significant numbers of patients waited much longer than these average response times, as was the case with Sophie. I am sorry we were unable to provide a better service to Sophie and others at this time. YAS operates within a broader system. Pressure was also experienced within this wider healthcare system, with associated difficulties in the timely discharge of patients to the most appropriate care settings, consequently reduced patient flow through acute hospitals, ultimately leading to extended handover delays with Emergency Departments. NHS Recovery Plans In January 2023, NHS England published its Delivery Plan for recovering Urgent and Emergency Care (UEC) services to respond to the challenges we had faced across the country. To support recovery, the plan set out two key ambitions:
• Patients being seen more quickly in Emergency Departments: with the ambition to improve to 76% of patients being admitted, transferred or discharged within four hours by March 2024, with further improvement in 2024/25.

• Ambulances getting to patients quicker: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels.

Since April 2023, the three Integrated Care Boards (ICBs) across Yorkshire and Humber have worked jointly through an Executive Leadership Board (ELB) with YAS to agree joint priorities and to improve performance and allocate additional investment. This investment is aimed at recruiting additional ambulance crews, developing new ways of working to avoid conveyance to hospital and investment in new vehicles, all of which are aimed at being able to provide a timelier response and meet increasing demand. Within the Yorkshire and Humber region there have been improvements in response times subsequently with the average Category 2 times of 32 minutes and 26 seconds in 2023/24. In April 2024, YAS average Category 2 response times reduced

to 26 minutes and 3 seconds and in May 2024 the figure was 31 minutes and 21 seconds. Hospital Handovers and Ambulance Turnaround Times The correlation between handover delays at Emergency Departments and overall ambulance response times is widely acknowledged. Handover times vary amongst our acute trusts in the region. We seek to ensure the root causes are understood. During the calendar month July 2022, the mean ‘handover’ time within South Yorkshire was 37 minutes and 32 seconds. The most recent calendar month of reporting (May 2024) showed that the mean ‘handover’ times within South Yorkshire were 29 minutes and 47 seconds. Further work continues to support other improvements. In collaboration with the acute trusts, YAS has implemented Quality Improvement initiatives to improve handovers. This helps further reduce the amount of ‘lost ambulance handover time’ and allow ambulances to return to the respond to emergency calls in a more timely manner. As part of operational planning for 2024/25, South Yorkshire ICB has set out an improvement trajectory for hospital handover times to be reduced to an average of 19 minutes. This will require continued focus on quality improvement, operational management and leadership to support this improvement. Further support measures YAS and Sheffield Teaching Hospitals (including other South Yorkshire Hospitals) have agreed a new Joint Escalation Action Plan (JEAP), for when system pressures increase. This plan provides specific actions that organisations must employ to support the improvement of ambulance handover. Implementation of Duty to Rescue protocol - this protocol was introduced ahead of the winter period (2023/24) and is now enacted at times of significant operational pressure. On occasions when there are high number of ambulances waiting to handover patients, the protocol allows for senior clinical decision makers from YAS and our hospitals to agree to the rapid handover and timely release of an ambulance crew to attend to a specific 999 call, or one who has been awaiting conveyance and is deteriorating. The introduction of this protocol has been welcomed by all parties and allows for clinical risks to be better managed in the system. Alternatives to Accident and Emergency (A&E) Departments – more alternative pathways of care are available for use by YAS Ambulance crews or staff within the Emergency Operations Centre (EOC) to safely and appropriately avoid conveyance to hospital. YAS has worked with partners across the urgent and emergency care system to improve availability of these pathways, including through the development of Urgent Community Response (UCR) services. These respond to a patient in their own home within two hours of the call in an aim to meet people’s needs and avoid hospital attendance where appropriate. This also gives direct access pathways to

clinicians for Same Day Emergency Care (SDEC) at local hospitals, which allow ambulance crews to bypass A&E for suitable patients and therefore meet people’s needs and improve hospital flow and ambulance turnaround. The EOC have continued to invest in the clinical workforce using clinical navigators to assist in the identification of incidents suitable for an alternative response or which can be clinically assessed and given self-care advice. General Practitioners (GPs) have also been employed to both assist with remote assessment and also to support clinical decision making more generally to improve outcomes and ensure patients are directed to appropriate care relevant to their needs. The EOC continues to improve their referral processes to other services therefore appropriately diverting demand into alternative care pathways. A System Coordination Centre (SCC) has also been developed over the past year. The SCC exists to be a central co-ordination service to providers of care across the ICB footprint to enable a proactive system response to operational pressures and risks with the aim to support patient access to the safest and best quality of care possible. Governance This Regulation 28 has been discussed at the YAS Clinical Quality Oversight Group with senior clinical leaders of the constituent organisations to share the matters of concern raised across the Yorkshire and Humber region. This reports to the ELB which has oversight of the Ambulance Service in Yorkshire. Within South Yorkshire, this Regulation 28 report and matters of concern will be shared through the Urgent and Emergency Care Alliance Board made up of senior leaders from all of the constituent bodies. As an ICB we maintain our shared commitment with both YAS and our partner ICBs within Yorkshire and Humber to ensure we are delivering safe, high-quality services for patients, carers and their families. Thank you for bringing these concerns to my attention. I hope you can see that we are making progress on response times and striving to reduce handover times. If you require any further information, please do not hesitate to contact me.