Matthew Faulkner

East and North Hertfordshire NHS)

NHS Trust

Lister Hospital
Coreys Mill Lane
Stevenage
Herts SG1 4AB

Tel: 01438 314333
29 May 2018

Mr G Sullivan

Senior Coroner for Hertfordshire
The Old Courthouse

St Albans Road East

Hatfield

Hertfordshire

AL10 OES

Dear Mr Sullivan
Matthew Faulkner (Deceased)

| am writing in response to your Regulation 28 report to Prevent Future Deaths, dated 29
March 2018, regarding the above named. | was saddened to learn of the circumstances of
Mr Faulkner's death on 30 May 2017.

Whilst | am aware that this Trust was not directly involved in the Inquest, | entirely
understand why, having heard the evidence from the East of England Ambulance Service
(EEAS), you issued this report to ourselves, Luton & Dunstable Hospital and the Princess
Alexandra Hospital in Harlow.

As you will be aware, there is a national concern with regard to ambulance handover times at
Emergency Departments and it was pleasing to hear recently that the Government are
allocating additional funding to the ambulance service to assist with this. However, in this
particular instance and in general, we are acutely aware of how ambulance and hospital
services need to work together in improving the local situation.

In January 2017 we identified ambulance handover times as a key challenge within our
performance targets and in order to address this in March 2017 we sought external expertise
to reconfigure the handover process, our aim being to reduce handover times to the meet the
national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a
timelier manner.

Using the principles of lean management, all non-essential tasks were removed from the
handover process significantly reducing the workload of the nurse responsible for handover.
This reduced the time of handover from 14 min per patient to 5 min significantly improving
the department's ability to meet the peak demands. In practical terms this increased our
capacity to meet the target for 6 patients in a 30 min period, increased from 2 patients in a 30
min period.

Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder

It is noteworthy that at times demand will out strip capacity leading to breaches in the 15 min
target for some patients, whilst the average handover time may remain below 15 minutes.

However, as a result of the work described above the department achieved some of the best
average performance in the region and managed to maintain this until September 2017 as
demonstrated in the graph below.

Average Time to Handover Time
Ambulance

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In September 2017, we introduced new computerised patient record and observation
systems, which regrettably, though understandably, slowed down patient throughput,
specifically in the Emergency department. This in combination with winter pressures caused
the handover time to slip.

As a consequence of introducing the new systems we are regrettably unable at present to
confirm, with certainty, the actual Emergency Department activity (eg. flow of patients,
numbers waiting at any point) on 30" May 2017 to explain the ambulance delays relevant to
this incident.

We are conducting a focus week in June 2018, mirroring the methods we used to improve
the situation last year, in order to bring performance back to the same levels as in April 2017.
Having achieved the improvements required, the performance will be monitored on a weekly
basis and focus weeks conducted if performance Slips.

| hope you will agree that the above measures demonstrate our commitment to ensuring an
improvement in ambulance handover times within the hospital setting.

Yours sincerely

Nick Carver
Chief Executive

Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder

NHS

East of England
Ambulance Service
NHS Trust

Headquarters
Melboum ambulance station

Whiting Way
Melbourn

Cambridgeshire
SG8 6NA

30" May 2018

Geoffrey Sullivan
Senior Coroner Hertfordshire

Dear Mr Sullivan

| write further to an email received from Po Senior Support Officer, on 9 April 2018 to
which she attached a Regulation 28 Report to Prevent Future Deaths. This report was made by you
following the inquest into the death of Matthew Luke Faulkner, which concluded on 27" March 2018, and
the concerns you raised are outlined below:

e At the time of this incident, demand on the EEAST far outstripped the resources available to
them.

e That the current position regarding demand outstripping available resources is not significantly
different to that in May 2017.

¢ That the demands placed on the EEAS by the public are not sustainable. With, in the region of,
only 60% ambulance attendances resulting in admission to hospital for urgent care.

* That there are still significant delays on handover to hospital, exacerbating the lack of
ambulances being available to answer emergency calls.

In April 2017 NHS England and NHS Improvement commissioned an independent service review to
provide recommendations on the Best Service Model, Pricing Review, Capacity and Demand Analysis
and the Commissioning/Contract model. This was review was completed by Deloittes and ORH, a
company specialising in operational modelling for emergency and health services. The findings were
published on 11" May 2018 and recognised the resource gap between the existing funding for the Trust
and what is needed to meet demand. This is now factored into our emergency operations contract which
will see a 15% increase over the next two years. This funding will enable the Trust to increase its
frontline patient facing staff by 330 full time equivalent by 2020/2021. | enclose a copy of the service
review for your information. We are planning to arrange a further briefing for HM coroners in the coming
months.

Whilst this independent service review was being undertaken, nationally all ambulance services made
significant changes to the way we respond to our patients due to the implementation of the Ambulance
Response Programme. The Trust commenced the implementation of these new standards on the 18
October 2017, which involved allowing call handlers more time to assess 999 calls to determine which
patients required an immediate response; and changes to the call categorisation. The new system allows
for early recognition of life threatening conditions and is designed to free up more vehicles and staff to
respond to emergencies. | understand the Trust’s former Medical Director, wrote to you

Chief Executive: Robert Morton
Chair: Sarah Boulton
www.eastamb.nhs.uk

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in October 2017 outlining these changes and further detail can be found on: www.england.nhs.uk/urgent-
e n re.

The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to
support our Acute Trust colleagues throughout the winter. These teams were deployed to emergency
departments across the region where handover delays were continuing past 45 minutes, where no
immediate resolution of the situation is apparent and patients are waiting for an ambulance response in
the community. The aim was to minimise patient wait and maximise the availability of ambulances. The
teams worked collaboratively with emergency department staff to maintain the safety of patients in the
department along with ensuring awareness of those 999 patients who are waiting for a response. This
scheme stayed in place until March 2018.

Following the risk summit that took place in January 2018, an independent harm review was
commissioned by NHS Improvement. This review was conducted by the Medical Director at NHS
Improvement, an independent medical consultant and two of the Trust’s Clinical Commissioning Groups.

Recommendations from risk summit are outlined below:

e Improved capacity and demand forecasting for the ambulance Trust

¢ Early escalation of hospital handover delays, which has resulted in a new regional handover
protocol and operating procedure.

e That the Trust to continue to support reduction in handover to clear times

e Review of the PSIT and HALO (Hospital Ambulance Liaison Officer) functions

e Additional staff in the Emergency Operations Centre, specifically clinicians to support the
Emergency Clinical Advice and Triage Centre. This will enable appropriate prioritisation and more
lower cases to be triaged to free up resources most in need.

« Collaboration with CCGs to review the process of inter-hospital transfers.

This review also identified national learning for all ambulance services too:

Stricter adherence to welfare call process protocols

Review call triage scripts for patients who have fallen

Commissioners to support regional services e.g. falls response team

National review of emergency services e.g. if patient fallen and no harm, specifically in relation to
care home services

Review of certain care home policies e.g. no-lift policy

e Application of end of life care processes consistently in care homes

e Up-to-date directory of services e.g. GPs to call ambulance services directly to enable
appropriate information sharing

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| hope this assures you that the Trust is taking considerable action to manage our call demand and
utilise the resources available to use in the most efficient way. We are working to improve our capacity
by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with
the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most
importantly, we are continuing to educate the public around the appropriate use of the 999 service and
looking at innovative ways to support patients with complex needs (mental health street triage teams) or
to those who call frequently due to falls.

Please do not hesitate to contact me should you require any further information.

Yours sincerely,

Robert Morton
Chief Executive

Chief Executive: Robert Morton
Chair: Sarah Boulton

www.eastamb.nhs.uk
THISISEEAS)
driver

LUTON &
DUNSTABLE
UNIVERSITY
HOSPITAL

CLINICAL EXCELLENCE, QUALITY & SAFETY

Our ref: SC/RM/1860/04/18 Lewsey Road Luton LU4 0DZ
Tel: 01582 49 11 66 www.idh.nhs.uk

22 May 2018

Mr Geoffrey Sullivan

HM Senior Coroner for Hertfordshire

Coroner’s Service | Hertfordshire County Council
The Old Courthouse

St Albans Road East,

Hatfield

AL10 OES

Dear Mr Sullivan
Re: Regulation 28 Report to Prevent Future Deaths Dated 29 March 2018

| write in response to the Report pursuant to Regulation 28 of the Coroners (Investigations)
Regulations 2013, dated 29 March 2018, for Mr Matthew Faulkner, which was issued to
East of England Ambulance Service, Lister Hospital, Luton and Dunstable Hospital and

Princess Alexandra Hospital. The Report was received via email from your Senior Support
Office, I on Monday 9 April 2018.

We offer our sincere condolences to Mr Faulkner's family and friends for their loss.

This response is limited to Part 5 of the Regulation 28 Report “Coroner’s Concerns,”
concern numbered (4) “That there are still significant delays open handover to hospital,
exacerbating the lack of Ambulances being available to answer emergency calls.” | note
concerns numbered (1) — (3) are directed to East of England Ambulance Service (“EEAS’).

Firstly, we would respectfully submit that Luton and Dunstable Hospital were not made
aware of an inquiry having been opened on 6" June 2017 into Mr Matthew Faulkner's death
and of the Inquest held on 27" March 2018. As such, Luton and Dunstable Hospital did not
have an opportunity to take part in the Inquest and make submissions in respect of any risks
identified in the course of the inquiry and/ or respond to any submissions made by the
Interested Persons who attended the Inquest on 27" March 2018.

On 30" May 2017, between 17:00 and 22:00 hours, 19 ambulances were delayed at the
Luton and Dunstable Hospital. This consisted of 11 ambulances under 30 mins and 8
ambulances under 60 mins, amounting to 368 minutes in total. As it was the Tuesday post
Bank Holiday, ED attendances were expected to be high and indeed 326 patients attended
across the 24 hour period, higher than the rolling 30 day average of 296. 88 patients arrived
by ambulance which is within normal daily expectations. The bed reports from that day
indicates high numbers of patients in the department - at 4pm there were 67 patients in ED
and 8pm, 58 patients, which would have caused some overcrowding within the department.
Similarly due to the Bank holiday weekend, discharges were reduced compared with
normal; the Trust already had taken steps to mitigate this by using one contingency ward of

| UCL Chairman: Simon Linnett
Chief Executive: David Carter Luton and Dunstable
UCL Medical Schoo! Clinical University Hospital

Teaching Hospital NHS Foundation Trust

an extra 18 beds full, and creating two “outlier bays” within the Surgical bed base, creating

12 further contingency beds. Flow out of ED was challenging despite this, with consequent
ambulances offload being compromised. It is worth noting that the hospital typically has up
to 60 patients whose discharges are delayed due to issues outside the hospital.

Generally the L&D’s performance regarding ambulance handovers is considered to be very
reasonable. We have long adopted this metric as one of our triggers for patient flow
escalation, which is monitored carefully throughout a 24 hour period. We always act upon
handover delays if it becomes apparent that flow has reduced, and this is contained within
our four times daily bed report. The escalation process involves input from an executive
director and one of the medical directors. Whilst there is always room for improvement, the
Weekly Sitrep ending 4"" June 2017 shows that we had no ambulances waiting over 60
mins throughout the whole week. Attached to this letter is the East of England Ambulance
service data for the period in question, showing the position of the L&D and all other trusts
served by EEAST.

The L&D ED processes are designed to ensure timely handovers with joint decision making
taking place between the ambulance crew and the ED nurse in charge with regards to
safely offloading patients. If there are no cubicles immediately available, the duty ED
consultant is made aware and becomes involved, and the hospital control room are tasked
with resolving the situation. All ED patients are prioritised by clinical need and a continuous
clinical risk assessment of all patients is undertaken through the process of “ED rounding” —
this is based upon the Bristol Patient Safety Checklist as advocated by NHS Improvement.
This may mean that at times a patient who has not arrived by ambulance may be given
priority above an ambulance patient.

We are aware that other Trusts have taken the decision to cohort patients while still on
ambulance trolleys and still in the care of ambulance crews. This does nothing to resolve
the release of ambulance crews and indeed removes more crews from attending to 999
calls. In response to this, EEAST created a Patient Safety Intervention Team (PSIT),
consisting of 5 separate geographical teams each of between 3 and 6 clinical staff. These
teams would be deployed into hospitals that had problematic ambulance offload problems,
taking over the care of these patients while the hospital was unable to accommodate them
and thus releasing the ambulance crew and vehicle back into active response duty.
Although these PSIT teams were deployed on a daily basis to hospitals across
Hertfordshire, they have never been sent to the L&D.

It is the Trust's firm belief that it is not safe practice to cohort ambulance patients as these
are often the most vulnerable patients in ED having not yet been assessed. Therefore there
are a number of other steps taken to assess existing patients and their need for a trolley
whilst flexing both capacity within and nearby the department by using it in a different way
as well as cohorting stable patients awaiting inpatient beds and boarding patients on
inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in
from ambulances, and will transfer existing patients into hospital and assessment beds to
accommodate this. We will open further contingency areas as necessary in order to
proactively create space rather than react to deficiencies in it. We will transfer patients to
wards where beds will shortly become available even if the space has not yet become

available, thus temporarily increasing the capacity of a ward (this is referred to as
“boarding’).

All parts of the NHS are experiencing growing pressure with the increased demand in
services and Luton and Dunstable Hospital are committed to working with all health and
social care providers, as needed, to improve the quality of care and coordination between
diverse services to ensure patients are kept safe.

Clearly, as partners working together with EEAS, we will continue to work collaboratively to
improve services we provide to our patients and the wider local populations, as needed.

Please do not hesitate to contact me if you require any further details.

Yours sincerely

David Carter
Chief Executive Officer

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NHS

The Princess Alexandra
Hospital
NHS Trust

Princess Alexandra Hospital
Hamstel Road

Harlow

Essex

CM20 10X

Mr Geoffrey Sullivan
HM Senior Coroner
The Old Courthouse
St Albans Road
East Hatfield

AL10 OES

29" May 2018

Dear Sir
Re Regulation 28 PFD report M Faulkner

Further to your Prevention of Future Death report dated 29" March 2018 please find below
Princess Alexandra Hospital NHS Trusts response to your concerns in regard to waiting time of
ambulances delivering patients to our Emergency Department.

The Trust are committed to ensuring that delays in offloading patients from ambulances are
both minimised and escalated in a timely manner. | can assure you that the Medicine Health
Care Group have introduced a number of process to prevent delays, these include

Refurbishment of the Emergency Department- completed in December 2017
The Emergency Department (ED) team have actively worked to reshape and redesign the
physical environment and pathways of care for our patients attending the department. The
team have maintained a clear focus on improving a number of areas some of which include
the following:

e Introduction of the Steaming Process

e Rapid Assessment of patients (RAT)
e Improvements to the ambulance handover

Rapid Assessment of Patients (RAT)

The introduction of the RAT process aims to ensure that patients are seen and assessed
within 15 mins regardless of their mode of arrival. The RAT process is consultant led.

The development to the RAT process is currently being run as a Plan Do Study Act (PDSA)
improvement methodology, the data collected has been used to develop and refine the
process. As yet formal audits have not been completed however our staff have designed an
audit which they believe will evidence the impact of the process.

Improvements to Ambulance handover

Our staff have a clear understanding that.as soon as patients arrive in the ED they are our
responsibility. The management of the ambulance arrival process is allocated to a Nurse and
Doctor who is responsible for the patients at all times.

Chair: Alan Burn CEO: Lance McCarthy
www.pah.nhs.uk

Whilst every effort is made to ensure that patients receive their initial assessment within 15
minutes, there are at times of peak demand, or when a number of ambulances arrive at the
same time, patients who may have to wait in the designated ambulance queue area which is
integral to the ED.

There is a clear escalation process which staff will follow should there be an issue with
queuing ambulances or a delay in ambulance handover of greater than 30 minutes. Our staff
will initiate the ambulance handover escalation process and the priority will be given to the
patient who requires the most urgent attention.

In addition between the hours of 07.30 and 02.30 this area is further supported by an
allocated Paramedic whose role is to continuously monitor the patients in this area and
escalate any concerns.

Real time Data

The Trust has implemented real time data, which is visibly available to all Emergency
Department staff, allowing timely escalation of issues and redeployment of resources across
the Emergency Department.

The Trust continues to work at improving the care provided to our patients and will continue to
monitor that the improvements in our processes have made a positive impact and will continue to
reduce the waiting times of emergency ambulances delivering patients.

The Trust hopes you are reassured by improvements made at Princess Alexandra Hospital NHS
Trust which aim to reduce the risk of any future deaths in relation to delays for emergency
ambulances.

Yours faithfully

Deputy Chief Executive and Chief Nurse

Chair: Alan Burn CEO: Lance McCarthy
www.pah.nhs.uk