Dennis King

Dear Coroner

Re: Regulation 28 Report to Prevent Future Deaths – Dennis John William King who died on 13th December 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15th January 2024 concerning the death of Dennis John William King on 13th December
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dennis’ family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Dennis’ care have been listened to and reflected upon.

In your Report you raised four matters of concern, which I address below.

1. Availability of ambulances to carry out transfers in a timely manner

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, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery Plan for Recovering Urgent and Emergency Care Services. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times (specifically for Category 2 patients), increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.

2. Inter-hospital transfers process The National framework for inter-facility transfers was published by NHS England in July 2019 and updated in March 2021. The framework is intended for patients who require transfer by ambulance between facilities due to an increase in either their medical or nursing care need. The framework states that patients going directly to theatre for primary percutaneous coronary intervention should receive an IFT Level 2 (IFT2) Category 2 response and that the clinical staff responsible for the patient National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

11 March 2024

determine that transfer to another healthcare facility is clinically necessary. If an ambulance is not immediately available for dispatch this incident should be escalated within the ambulance emergency operations centre to ensure an appropriate response. Ambulance trusts should have appropriate clinical support and decision- making processes in place for transfers requiring escalation.

NHS England has also engaged with West Suffolk NHS Foundation Trust (WSFT) on the coroner’s concerns. We understand from WSFT that Dennis’ care was reviewed internally by their Patient Safety and Inquest Teams who found no reason for formal review. Clinicians within the Emergency Department have however been reminded of the opportunity to escalate concerns around emergency transfer of patients to the relevant tactical and strategic commander as this could expedite any transfer.

3. The suitability of the NHS approach to centralising exigent care in regional centres In December 2006, the Department of Health published the report “Mending Hearts and Brains – clinical cases for change.”, advocating and providing the rationale for a primary percutaneous cardiac intervention (PPCI) service, running 24 hours a day, 7 days a week, as a first treatment for heart attacks. Percutaneous coronary intervention (PCI) is a non-surgical procedure to treat the blockage in a coronary artery. The report stated that by bypassing local hospitals to deliver PPCI to heart attack victims within centres of excellence could save an estimated 500 lives and may prevent around 100 further heart attacks and 250 strokes annually.

The national PPCI Programme was established following the National Infarct Angioplasty Project, completed in 2008, which showed a reduction in hospital mortality (5.2% v 7.1%) and 18 month mortality (9.9% v 14.8%) for patients treated with PPCI as opposed to thrombolysis.1 PPCI was judged to be superior to thrombolysis if the infarct artery could be opened within 150 minutes of the call for help which was applicable across 95% of the UK population.

Evidence supports improved outcomes when PPCI services are provided by a specialist centre with skilled clinical teams, where sufficient numbers of cases justify provision of a 24/7 staffed service. Specialised services cannot be provided in every hospital which can create challenge when patients require a transfer for specialised treatment, particularly when ambulance resources are under pressure. Increasing the number of specialised centres for PPCI centres would require careful consideration and scoping to ensure there is sufficient specialised activity to support expanding the number of commissioned centres to deliver a PPCI service, ensuring standards and outcomes and existing services are not compromised.

1 Thrombolysis is a treatment to dissolve or break up a blood clot. It is an option for patients facing delays to interhospital transfer. It has been superseded by PPCI in terms of clinical effectiveness for the treatment of heart attacks.

The clear consensus of the Cardiac Services Clinical Reference Group2 was that PPCI patients should be treated in dedicated centres which offer 24/7 cover. Continuous cover for PPCI requires a 24/7 rota to fully staff a catheter lab equipped to deal with complex and high-risk cases supported by ward teams familiar with the presentation and complications of a heart attack. This concentration of expertise is only available in dedicated centres and so requires centralisation of care.

Patients who self-present to a non-heart attack centre with a heart attack are subsequently conveyed to a heart attack centre as a Category 2 ambulance call. This transfer can build in substantial delay to treatment, which will be longer than for patients transferred directly from the community.

In February 2022, NHS England launched its first ever public awareness campaign on heart attack symptoms. The “Help Us Help You – Heart Attack” campaign aimed to increase public awareness of heart attacks and address the barriers to acting quickly on symptoms. It emphasised the importance of calling 999 so that symptoms can be evaluated promptly.

Some hospitals with catheter labs that perform PCI but which are not heart attack centres are capable of performing PPCI in patients who self-present in their emergency departments to avoid the wait for an inter-facility transfer. This is dependent on the availability of local expertise and the absolute numbers of patients involved are small. Work is being undertaken to improve communications between the ambulance teams and PPCI centres to minimise the rate of inappropriate activations of PPCI teams where the patient does not have a heart attack.

4. Adequacy of action plan provided to the court by East of England Ambulance Service NHS Trust (EEAST) It is not within NHS England’s remit to comment on the adequacy of the action plan provided to the court by EEAST and we would refer you to the Trust on this issue. We understand that their action plan is under review and once updated will be sent to you.

I would also like to provide further assurances on the national NHSE 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 events are shared across the NHS at both a national and regional level and helps us to 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 Mr Stewart I am writing further to the inquest into the death of Dennis John William King, which concluded on 29 November 2023. I understand that the Trust were not Interested Persons and no Trust witnesses were required to give evidence at the inquest to provide further information in relation to our action plan. Following the inquest, you made a Regulation 28 Preventing Future Death report on 15 January 2024 outlining your concerns for the availability of ambulances to respond to transfers and 999 calls; lack of clarity between ambulance and hospitals in relation to transfer requests; the adequacy of the action plan provided by the Trust; and the appropriateness of centralising care in regional centres. I have not commented on the latter concern as it is outside the scope of the ambulance service. Availability of ambulances to carry out transfers in a timely manner The Trust has a range of specific actions in place to improve response times to patients which include:
• Additional recruitment with the aim for there to be over 300 more frontline clinicians in place by March 2024.
• Additional recruitment of clinicians within our control environment, allowing for greater volume of clinical triage to improve patient safety and to transfer patients to alternative services where appropriate. This is supported by the establishment of an Unscheduled Care Coordination Hub within Suffolk where we are working with the Integrated Care Board, the 111 provider and community services to increase referrals of appropriate patients to alternative services and to provide remote support to crews on scene.
• The implementation of our Operational Performance and Improvement Plan, which is our plan to improve our own efficiency as an organisation and to maximise ambulance availability. I attach a presentation on OPIP with this letter to provide an update on this work. Meeting the C2 response time has been a challenge for all ambulance services. Modelling by NHS England (NHSE) demonstrates there is a strong relationship between hospital handover delays and the ambulance C2 performance. NHSE’s regression model indicated that based on previous performance, in order to reach an average response time of 30 minutes for C2 patients,

a maximum of 1,500 lost hours per week should not be exceeded (see graph below). Equally if more than 1,500 hours are lost per week, the C2 response time is unachievable. The Regional NHSE oversight meetings have been formed to support this important maximum standard. Currently levels exceed this significantly and in Q2 weekly lost hours exceeded 2,582 hours per week. Specifically in Suffolk, we have been engaging with the local Acute Trusts to reduce delays, which has started to have a positive effect on the number of our vehicles delayed at hospital. The Trust is also working with our ICB colleagues in Suffolk and across the region to implement the ‘Call before you convey’ programme. This allows frontline clinicians to speak with senior clinical advisors before making a decision on conveyance and check the most appropriate pathway for the patient is being followed. In the past month, the Trust has implemented the same-day emergency care team at West Suffolk Hospital to ensure patients are attending the right facility at the right time to avoid unnecessary handover delays in the Emergency Department. In addition to this, in Suffolk, a mental health joint response car has recently been implemented jointly with the Norfolk and Suffolk Foundation Trust and a 24/7 advanced practice paramedic car is also now live in the Suffolk area. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers The National Framework for Inter-Facility Transfers is produced by NHS England and we will endeavour to review this framework with NHS England in light of Mr King’s death. I can confirm that the call has been reviewed and at no point was the hospital matron informed that the patient was at a place of safety when she challenged the timeframe. The call handler gave appropriate information during the call in relation to call categories and delays. I am happy to share this call recording with you if required.

Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 calls the plan is generalised, lacking detail and any means of measurement of progress. The action plan disclosed to you is an information sheet shared with families where a Serious Incident (as they were referred to at the time) is declared and the aim is to provide a high-level overview of the actions the Trust is taking to tackle the demand challenges we face. The plan provided to you was an existing version and has been updated a number of times since this incident. It is currently under review and, once approved, we will share an updated copy with you. The OPIP (as outlined above) is the more detailed action plan that the Trust has had in place to improve response times. In light of your comments on this matter, the Legal Services Team is reviewing the information we share with Coroners when the initial request for records is received to ensure we are providing the most appropriate and up-to-date information to support the coronial process. We are continuing to work with NHSE and our other healthcare partners to improve our response times to our patients. Please do not hesitate to contact me should you require any further information.