Lee Caruana

•Department 

of Health & 
Social Care

Miss Emma Brown 
HM Area Coroner 
Birmingham and Solihull Coroner's Court 
Steelhouse Lane 
Birmingham 
B46BJ 

'JJ;t- November2022 

Dear Miss Brown, 

Thank you for your letter of 16 June 2022 about the death of Mr Lee Anthony Caruana.  I am 
replying as Minister with responsibility for Health and Secondary Care, and thank you for the 
additional time allowed. 

Firstly, I would like to say how saddened I was to read of the.circumstances of Mr Caruana's 
death and  I offer my sincere condolences to his family and  loved ones.  The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention. 

In  preparing this  response,  Departmental  officials  have made  enquiries with  NHS  England 
(NHSE), as well as·the relevant regulator in this case, the Care Quality Commission. 

The government is committed to supporting the ambulance service to manage the pressures 
it  is  facing,  ensuring  that  people  receive  the  treatment that they  need  when  they  need  it. 
Ambulance trusts receive continuous central monitoring and  support from  the NHSE funded 
National Ambulance Coordination Centre, and there is a range of support in place to improve 
performance. 

NHSE  has  allocated  £150  million  of  additional  system  funding  for  ambulance  service 
pressures  in  2022/23,  supporting  improvements  to  response  times  through  additional  call 
handler  recruitment,  retention  and  other funding  pressures.  NHSE  has  also  tendered  a 
procurement contract for auxiliary ambulance services with a total value of £30 million.  This 
contract will provide national surge capacity as  needed to support the ambulance response 
during periods of increased  pressure by enabling fully equipped  and  crewed  ambulances to 
be deployed in localities during times of surge pressure.  In addition, the Ambulance Auxiliary 
provider  is  expected  to  support the  NHS in  the event of major incident or other disruptive 
challenge through the provision of flexible clinical and  logistical resource. 

Further to this, the Department has made significant investments in the ambulance workforce. 
The  number  of  NHS  ambulance  and  support  staff  has  increased  by  almost  40%  since 
February 2010, and Health Education England has a mandated target to train 3,000 paramedic 
graduates nationally per annum from 2021-2024, further increasing the domestic paramedic 
workforce to meet future demands on the service. 

In addition, national 999 call handler numbers have been boosted to over 2,300 at the start of 
May  2022,  about  400  more  than  September 2021,  with  p·otential  for services  to  increase 

 
 capacity further d,uring 2022/23.  A £1.3  million national campaign for the 999 call handlers 
was initiated in March to support trusts.  This is alongside a £50 million  national investment 
across  NHS  111  in England for 2022/23 to  support additional  NHS  111  capacity to  ensure 
people  get  the  care  they  need  when  they  need  it  and  avoid  unnecessary  demand  on 
ambulances.  This builds on additional investment from last year. 

In  July 2021,  NHSE  allocated  an  additional £4.4  million to  ambulance  services  to  support 
retention of emergency ambulances and thereby increase the fleet for winter.  This improved 
service  capacity,  keeping  154 fully  equipped  vehicles  on  the  road.  To  further  increase 
ambulance  capacity,  £20  million  of capital  funding  will  be  invested  in  each  of the  financial 
years 2022/23, 2023/24 and 2024/25. 

Additionally,  NHSE  has  undertaken  targeted  support  to  some  of the  hospitals  facing  the 
greatest delays in the handover of patients from ambulances into the care of hospitals, helping 
them  to identify short and  longer term interventions to improve delays and .get ambulances 
swiftly  back  out  on  the  road.  Work  is  taking  place  across  all  Integrated  Care  Boards  to 
determine  the  amount  of capacity  needed  to  support  performance  and  how  this  can  be 
delivered.  Focus  remains  on  improving  flow,  including  maximising alternative  pathways to 
Emergency  Department  {ED)  and  reducing  occupancy  through  the  work  of  the  National 
Discharge  Taskforce  with  membership  from  local  government,  the  NHS  and  national 
government.  Local  health  and  social  care  partners  are  already  standing  up  the  use  of 
additional action to support discharge and  improve  patient flow.  Ambulance  services have 
been  working closely with  their local  systems to reduce  avoidable conveyance  and  support 
patients to get the care they need outside of hospital; conveyance rates to ED are the lowest 
ever outside periods of national lockdown. 

Finally,  in  2020/21,  £450  million  was  invested  to  upgrade  A&E  facilities  in  175  smaller 
schemes and 25 major schemes.  This was used to boost physical capacity in A&Es through 
expanding  waiting  areas  and  increasing  the  number  of  treatment  cubicles,  reducing 
overcrowding and  supporting social distancing throughout the pandemic and helping to clear 
ambulance queues  more  quickly.  This  continued  in  2021-22 with  investment in  25  major 
schemes,  which  so  far have  delivered  382  waiting  spaces,  175  major  cubicles,  42  resus 
cubicles, and  177 SDEC cubicles. 

To  drive  further  progress  and  support  regional  and  local  system  arrangements,  the 
Department  has  established  a  national  discharge  taskforce  with  membership  from  local 
government,  the  NHS and  national government.  Local  health and  social care partners  are 
already standing up the use of additional action to support discharge and improve patient flow. 
We  will  continue  exploring  options  that  minimise  delays  to  hospital  discharge,  including 
identifying  capacity to accommodate  people  who  no longer need  acute hospital  care while 
continuing to need other forms of support. 

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

Yours sincerely, 

WILL QUI.NCE MP 

MINISTER OF STATE FOR HEALTH

1st Floor  
Wesleyan 
Colmore Circus 
Birmingham B4 6AR 

19th July 2022 

Miss Emma Brown  
HM Area Coroner for Birmingham & Solihull  

Dear Miss Brown  

Your Ref: 17372444 - Lee Anthony CARUANA (

I am writing in response to the Regulation 28 issued following completion of the inquest on June 
14th 2022, into the sad death of Lee Anthony Caruana on October 6th 2021. I extend my sincere 
condolences to the Mr Caruana’s family. 

I note the narrative conclusion of the inquest as ‘Death was due to natural causes contributed to 
by a delay in ambulance attendance’. I also note your statement ‘in the circumstances it is my 
conclusion that the availability of ambulance crews is being compromised by delays at hospitals 
resulting in delays in response times which creates a risk to life’. The delay in handover of patients 
from  an  ambulance  into  an  Emergency  Department  (ED)  is  a  well  described  current  problem 
within the NHS.  This bottleneck is a symptom of flow along a complex, system-wide pathway, 
starting with citizens seeking medical help and ending with the timely discharge of patients back 
home or into a suitable residential location. All system partners have their part to play to ensure 
flow and efficiency is optimised, whilst safe and effective care is maintained. 

Flow  along  this  pathway  was  a  problem  prior  to  the  COVID-19  pandemic  with,  for  instance,          
deterioration in metrics of ED performance. However, as we recover from the pandemic this has 
significantly deteriorated. The causes for this are multifactorial and include, as examples, infection 
control limitation in space utilisation, workforce reduction through sickness, fatigue and high turn-
over,  increased  demand  across  all  aspects  of  healthcare  and  ongoing  high  bed  occupancy 
throughout all bedded healthcare provision. 

Birmingham and Solihull (BSOL) are very focused on the major risk posed by delay in ambulance 
handover to the care of others within the system. A major piece of work was instigated in late 
2021, involving all partners, to ensure efficiency of flow within required pathways. This remains a 
major priority for the newly formed Integrated Care Board (ICB). 

Before I describe these changes in practice in detail, I will address some of the specifics of this 
particular case. 

 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 I note that Mr Caruana first called 999 at 14:44 on Oct 5th 2021 and a decision to respond was 
only made nine hours later at 23:53 after several further calls to 111/999 during the afternoon and 
evening. At this point, the response was classified as a ‘category 2’ but it is stated that ‘due to the 
pressures on the ambulance service’ an ambulance was not available for just under three hours 
until 2:42, arriving at 03:10. Records show that Mr Caruana arrived at Queen Elizabeth Hospital 
at 03:51 and was handed over to medical teams by 03:56 at which point he was critically unwell.  
Despite  all  clinical  efforts  he  unfortunately  continued  to  deteriorate  and  sadly  passed  away  at 
05.38.  

The  Root  Cause  Analysis  performed  by  WMAS  and  reviewed  by  Black  Country  and  West            
Birmingham  CCG  in  their  role  as  host  of  the  regional  WMAS  commissioning  team,  identified      
concerns  with  call  handling  leading  to  delay  in  decision  to  respond,  in  addition  to  the  delay  in 
arrival of an ambulance to convey because of significant operational pressures.  

As Birmingham and Solihull (BSOL) CCG, and now as an ICB, there has been a refresh of the 
Urgent and Emergency Care (UEC) programme, commencing in late 2021. This has included a 
change in governance including two periods of escalation into category 4 incidents with system 
Gold Command (first due to Omicron December 2021 – March 2022 and then April 2022 – May 
2022),  system  Multi  Agency  Discharge  Events (MADE)  events  held  January  2022  and  system 
UEC quality summits held in March 2022.  

One of the major priorities of the newly formed ICB is an immediate commitment to production of 
a system wide Urgent and Emergency Care strategy involving all ICS stakeholders with a current 
two  week  multi-stakeholder  improvement  event  to  ensure  a  further  step  change  in  delivery.       
Governance  arrangements  have  been  further  re-defined  for  strategic,  tactical  and  operational    
interventions. This is in addition to an ongoing forensic focus, both within individual organisations 
and at system level, to ensure that flow through the relevant pathways with joined up, integrated 
working remains a high priority. This work is described in greater detail below.  

I hope that this summary of actions across a complex pathway assures you that BSOL ICS and 
ICB has recognised the importance in driving change to not only reduce the risk held by WMAS 
with regards to their community response, but to ensure that going forward we have effective and 
efficient Urgent and Emergency Care delivery for the citizens of BSOL.  

Yours sincerely 

ICB Chief Executive  

Enc  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Pre-hospital care: 

Within West Midlands Ambulance Service (WMAS): 

WMAS has one of the lowest conveyance rates to hospital in the country and continues to work 
within this system to  build on care that supports patients away from EDs. This includes: 

• 

• 
• 

increase in ‘hear and treat’ and ‘see and treat’ categories with robust clinical validation and 
audit.  
conveyance to alternative destinations such as Same Day Emergency Care (SDEC) units  
referral by crews to community alternatives such as General Practice and Urgent Commu-
nity Response where appropriate. 

General Practice (GP): 

Demand within General Practice has been higher than pre-pandemic levels for some months, a 
pattern seen across the country. Within BSOL there have been several projects established to 
support and expand Primary Care capacity to help reduce attendances at ED where not clinically 
required.  

These include: 

•  Local Improvement Schemes to improve call flow and website development 
•  Weekly direct contact with GP practices to ensure maintaining resilience with a co-ordi-

• 

nated support offer where required 
Implementation of contractual extended access service at 33 hub locations providing ap-
prox. 10,600 additional primary care appointments per month 

•  Additional primary care winter surge appointments at five locality sites directly bookable as 
overflow by GP teams or NHS111. This provided an additional 440 face to face appoint-
ments daily. Capacity has been maintained within East Locality 

•  Additional Bank Holiday capacity in April- June providing 1600 additional appointments to 

support emergency care 

Urgent Community Response: 

Both Birmingham and Solihull Community teams have a 2 hour Urgent Community  Response 
(UCR)  in  place  covering  the  nationally  mandated  7  days  a  week  8am  to  8pm  coverage.  This 
service is 

• 

Integrated into existing community resources to ensure access wide referral access and 
ongoing care provision 

•  Providing response to calls that would otherwise require a WMAS category 3 response 
•  Supported by independent ambulance service to aid with transport and falls management 
•  Close working with WMAS to maximise referral routes 

Older People’s Advice and Liaison Service (OPAL+): 

OPAL+ facilitates a virtual MDT consultation between paramedics in a patient’s home and the 
QEHB-based OPAL team with the aim of supporting the patient to remain at home and avoid a 
conveyance to hospital.   

 
 
 
 •  Most as a telephone call with project in place to test  technology enabled virtual consulta-

tions; including a camera headset, ECG and digital stethoscope.   

•  Ambulance conveyances avoided for over 70% of calls.   
•  Access  extended  to  community  nursing  teams  (including  UCR)  across  Birmingham  and 

Solihull 

Care home support: 

Birmingham  and  Solihull  Enhanced  Health  in  Care  Homes  is  in  place  across  Birmingham  and 
Solihull (EHCH) – which includes primary care and community support.  

•  Enhanced support model in 26 nursing and residential care homes for older people across 
Birmingham (c.1300 beds) to test a rapid response team of advanced nurse practitioners 
(ANPs) and clinical support staff. Provides support across a wide range of care processes 
including reducing hospital admissions 
‘Support to care homes’ team present in Solihull including community matrons  

• 

At Hospital Front Door: 

University Hospitals Birmingham provides the majority of care (and all adult care) via Emergency 
Departments within BSOL with a yearly  attendance of 388,540 across UHB (March 21 – April 22) 
that equates to the following per ED site.  

•  Birmingham Heartlands Hospital – 161,114 
•  Good Hope Hospital  – 98,460  
•  Queen Elizabeth Hospital – 128,966 

A series of transformations have been undertaken to aid flow through both emergency pathways 
and discharge pathways to enable flow. 

Hospital Streaming 

• 

In place on all three acute hospital sites to ensure attending patients appropriately directed 
to correct care at first point of contact,  re-directed away from ED services where appropri-
ate.  

•  Patients then conveyed or diverted directly to appropriate assessment units, Same Day 

Emergency Care units (SDEC) and ED Primary Care services rather than into ED itself.  

Same Day Emergency Care (SDEC) 

Same Day Emergency Care (SDEC) activity is emergency care provided outside of the ED itself, 
for instance within a Surgical, Medical or Gynaecological Assessment unit.   

•  At UHB significantly increased with 13% of emergency activity now being managed through 

SDEC (6% prior to project commencement) Aim to continue to increase.  

•  Local General Practitioners involved in SDEC activity enabling prompt and safe transfer 

• 

back to community General Practice where appropriate.  
Introduction of Surgical Assessment  virtual wards for defined patient cohorts in order to 
facilitate safe, early discharge.  

 
 
 
 
 ED Primary Care Streaming  

In recognition that a proportion of  ED attendances could be managed by primary care services, 
BSOL CCG commissioned five GP providers to pilot an on-site Primary Care Service.   

•  Provides a total of 198 appointments per weekday and 204 appointments on a Saturday 

and Sunday.  

•  May 2022 9.3% of patients attending ED at UHB were successfully diverted to this path-

way. 

Cohorting by WMAS staff at UHB 

WMAS ambulance staff provide a cohorting service at all three ED sites.  

•  area within the hospital staffed by a double ambulance crew caring for up to 10 patients 
• 
•  HALO is provided for each site by WMAS who co-ordinates the care of patients remaining 

facilitates unloading of patients into a safe area prior to ED review.  

under the ambulance service.  

Ward Care: 

Efficient care for inpatients is crucial to ensure flow through inpatient pathways and timely dis-
charge. This flow enables timely admission and reduced delay in ambulance handover. 

•  UHB quality improvement programme to ensure safe, effective and efficient care for inpa-

tients, led by the Chief Medical Officer and his team.  

•  Addresses developments in clinician’s decision making across several areas of care, in-
cluding  effective  ward  rounds,  treatment  escalation  and  limitation  decisions,  end  of  life 
care, communication with patients and relatives and discharge processes.  

Timely discharge: 

The programme of work described above within ward care is important to allow timely discharge. 
In addition a hospital length of stay programme is underway. 

•  Focuses  on  defining  when  a  patient  is  medically  fit  and  an  expected  date  of  discharge, 

• 

effective multi-disciplinary meetings and a discharge bundle.  
Implementation of Criteria to Reside metric directly linked from Electronic Health Record 
to ensure consistency of measurement 

•  The Discharge Bundle implements discharge planning in a more structured way; checklist 

of key tasks that need to be completed 72 hours, 48 hours, and day of discharge.   

Complex Discharge 

Within the Complex Discharge Hubs  there have been a number of initiatives to support UHB with 
increased  and  earlier  discharges  working  closely  with  colleagues  in  Birmingham  Community 
Healthcare Trust and within local authorities. These include;   

-  Changing processes for discharges to community wards to make more efficient decreasing 

length of stay of patients in the acute hospital.  

 
 
 
 -  Standing down some of the infection control procedures for patients going through Path-
way 1 (patients being discharged into their own homes) decreasing the number of failed 
discharges and the length of stay of patients in hospital.  

-  Solihull Home First Diagnostic – to identify areas of opportunity to ensure that patients are 

being discharged at the earliest appropriate opportunity to the right care setting.  

-  Flow  co-ordinator  post  implemented  in  Solihull  to  support  with  more  effective  discharge 

planning for Solihull Local Authority patients who require a step down bed.  

-  Commissioned  increase  in  community  beds  both  within  Birmingham  Community 
Healthcare  Trust  and  the  independent  sector  to  ensure  bed  availability  is  not  a  limiting 
factor to complex discharge from acute services. Close working with local authority col-
leagues with trusted assessor models has enabled efficiency in discharge both from acute 
sector beds and from community beds to final residential destination.  This has also been 
aided by commissioning of additional ambulance support for complex discharge patients.  

Virtual wards 

All systems were asked to develop virtual wards in response to NHSEI planning guidance.  These 
‘beds’ will be used to facilitate early supported discharge and admission avoidance and thus free 
up hospital bed capacity and support reduction in ambulance turnaround times.  

•  The BSOL virtual ward plan developed by all system partners and funding agreed.   
•  Builds on a small but well established baseline (currently 45 beds for Chronic Obstructive 
Pulmonary Disease and Urgent Community Response) created in January 22 with the am-
bition of delivering a total of 340 virtual ward beds by April 2024.   

•  Further respiratory conditions will be added and virtual ward capacity created for frailty, 

surgery, cardiology and diagnostic pathways.   

Mental Health: 

There have been a number of initiatives to improve the experience and outcome for citizens who 
present  in Acute  Hospitals,  and  who  require  an  ongoing  mental health  pathway  following  their 
attendance within ED.   

•  daily  morning  meeting  across  providers  reviews  mental  health  attendances  and  admis-
sions into the Acute Hospital to agree ongoing plans and transfers to Acute Mental Health 
units when patients are medically fit for transfer.   

•  The mental health 24/7 helpline continues to receive 350-450 calls per week from citizens 
reaching out for mental health support.  This includes clinical support that helps to direct 
citizens to appropriate pathways of support outside of emergency departments, where ap-
propriate.  

Opening of an All Age Urgent Care mental health centre at the Oleaster site of the Mental Health 
Trust in the Spring of 2022.  

 
 
 
 
 
 •  Hosts  a  Psychiatric  Decision  Unit  (PDU)  and  Place  of  Safety  (PoS),  for  under  18’s  and 

over 18’s 

•  Provides a supportive and effective service within a purpose-built environment. 
•  Helps  to  support  a  reduction  in  the  number  people  experiencing  a  mental  health  crisis 

being taken by ambulance to ED and thus improve their care

Miss Emma Brown 
HM Area Coroner for Birmingham and Solihull 
Coroner's Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

National Medical Director  
NHS England  
Wellington House 
133 - 155 Waterloo Road 
London 
SE1 8UG 

14/09/2022  

Dear Miss Brown, 

Re: Regulation 28 Report to Prevent Future Deaths – Lee Anthony Caruana 
who died on 6 October 2021  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  16 
June 2022 concerning the death of Lee Anthony Caruana on 6 October 2021. I would 
like to express my deep condolences to Mr Caruana’s family.  

Following  the  inquest,  you  raised  concerns  in  your  Report  regarding  the  delay  in 
ambulance  attendance.  You  concluded  that,  from  a  national  perspective,  the 
availability of ambulance crews is being compromised by delays at hospitals, resulting 
in delays in response times which creates a risk to the life.  

For NHS England (NHSE), resolving handover delays and the related impact on 
ambulance response is of the highest priority. A national letter (Appendix A) was 
issued jointly from NHSE and the Care Quality Commission in February 2022, 
setting out the need for integrated care systems to come together to address the risk 
of harm to patients in the community caused by long delays in handing over patients 
at Emergency Departments. This was followed up with meetings between systems 
and the NHSE Chief Operating Officer, where systems were asked to set out plans 
to tackle handover delays and share risks across health and care services at system 
level.  

In  addition,  NHSE  set  out  the  next  steps  in  increasing  capacity  and  operational 
resilience in urgent and emergency care ahead of winter, in a letter on 12 August 2022 
(Appendix  B).  This again  highlighted  the need  to  target  Category 2  response  times 
and ambulance handover delays.  

NHSE continue to provide targeted support to some of the hospitals facing the greatest 
delays  in  the  handover  of  patients,  helping  them  to  identify  short-  and  longer-term 
interventions to improve delays and get ambulances swiftly back out on the road. The 
10  trusts  with  the  highest  amount  of  hours  lost  to  ambulance  handover  delays  are 
receiving intensive support from NHSE (including capital and revenue as required). In 
addition,  NHSE  are  developing  a  wider  support  programme  for  all  acute  trusts  to 
deliver  improvements  in  ambulance  handover.    Work  is  taking  place  across  all 
Integrated  Care  Boards  to  determine  the  amount  of  capacity  needed  to  support 

                                           
 
 
                       
 
 
 
 
 
 
 
 
 
 
  
 performance  and  how  this  can  be  delivered.  Focus  remains  on  improving  flow, 
including maximising alternative pathways to Emergency Departments, and reducing 
occupancy through the work of the National Discharge Taskforce. 

Reducing avoidable conveyance ultimately reduces the number of ambulance crews 
attending  Emergency  Departments,  which  in  turn  will  reduce  handover  delays. 
Ambulance  services  have  been  working  closely  with  their  local  systems  to  reduce 
avoidable conveyance, and to support patients to get the care they need outside of 
hospital. Current conveyance rates to Emergency Departments are the some of the 
lowest  ever  outside  periods  of  national  lockdown.  Indeed,  ambulance  conveyance 
rates have fallen considerably in the last few years (from 59.1% in 2018-19 to 50.0% 
for July 22). An avoidable conveyance is when a patient, whose health and social care 
needs could be effectively and safely met in the community, within or close to their 
own  home  (or  an  alternative  setting  to  an  emergency  department),  is  conveyed  to 
hospital unnecessarily.  

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, such as the sad death of Mr Caruana, 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. 

I  note  the  response  from 
 the  Birmingham  and  Solihull  Integrated 
Care Board Chief Executive, and the initiatives being undertaken to improve patient 
flow within the Urgent and Emergency Care pathways.   

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. 

Yours sincerely, 

Appendix A 

Appendix B 

B1929_Next-steps-in-increasing-capacity-and-operational-resilience-in-urgent-and-
emergency-care-ahead-of-winte.pdf (england.nhs.uk) 

220217 B1401_Ambulance Service Pressures.pdf