Dennis King

From Helen Whately MP 
Minister of State for Health and Secondary Care 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

Darren STEWART OBE 
HM Area Coroner for the coroner area of Suffolk 
The Coroner’s Court and Offices 
Beacon House 
Whitehouse Road 
Ipswich IP1 5PB 

Dear Mr Stewart,  

 2 April 2024 

Thank you for your letter of 15 January 2024 to the Secretary of State for Health and Social 
Care Victoria Atkins, about the death of Dennis John William King. I am replying as Minister 
with responsibility for urgent and emergency care. Please accept my sincere apologies for the 
delay in responding to this matter and I am thankful for the extension you have granted. 

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr King’s death 
and I offer my sincere condolences to his family.  I am grateful to you for bringing these matters 
to my attention.  

Your report raised concerns about ambulance response times, delays in transferring patients 
to specialist units within the East of England, the centralisation of services and the action plan 
provided by the local ambulance trust. I understand that NHS England (NHSE) has written to 
you  to  respond  to  those  specific  concerns  within  their  remit  as  have  East  of  England 
Ambulance Service Trust (EEAST) on action being taken locally. NHSE note in their response 
note if ambulances are not available immediately for patient transfers, the incident should be 
escalated to ensure an appropriate response. 

I  recognise  the  pressures  our  A&E  and  ambulance  services  are  facing  and  the  impact  of 
waiting times for patients. That is why we published our ambitious Delivery Plan for Recovering 
Urgent  and  Emergency  Care  Services  which  aims  to  deliver  sustained  improvements  in 
waiting times. The ambition is for 76% of patients to be admitted, transferred, or discharged 
from A&E within four hours by March 2024, and to reduce Category 2 ambulance response 
times to 30 minutes on average this year. 

Your  report  highlights  that  EEAST  were  under  high  demand  at  the  time  of  the  incident.  A 
primary  aim  of  the  delivery  plan  is  to  boost  ambulance  capacity.  Ambulance  services  are 
receiving £200 million of additional funding this year to expand capacity and improve response 
times alongside the delivery of new ambulances and specialist mental health vehicles. With 
more ambulances on the road, patients will receive the treatment they need more swiftly.  

I recognise that ambulance trusts work within a health and care system and issues such as 
delayed patient handovers to hospitals can impact on capacity and response times. That is 
why a key part of the delivery plan is about improving hospital’s patient flow and bed capacity. 
We have met our planned targets of delivering 5,000 more staffed, permanent hospital beds, 
supported by £1 billion of dedicated funding, and increased virtual ward bed capacity to over 
10,000 ahead of winter. This builds on the £500 million used last winter and a further £1.6 

1 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 billion of funding over two years to support the NHS and local authorities to ensure timely and 
effective discharge from hospital. These measures are helping improve patient flow through 
hospitals,  reducing  delays  in  patient  handovers so ambulances  can  swiftly  get  back  on  the 
roads.    

Regarding  staffing  capacity,  we  have  made  significant  investments  in  the  ambulance 
workforce – the number of NHS ambulance staff and support staff has increased by over 50% 
since 2010. To help ensure we have the ambulance workforce to meet the future demands on 
the  service,  the  NHS  Long  Term  Workforce  Plan  sets  out  plans  to  boost  the  number  of 
paramedics by up to 15,600 to deliver services in ambulance and other care settings.   

At a national level, we have seen significant improvements in performance this year compared 
to last year. In the East of England this winter, average Category 2 response times were nearly 
a third faster. However, we know there is more to do and reducing waiting times is a priority of 
this Government. 

Thank you once again for bringing these concerns to my attention.  

Yours,  

HELEN WHATELY

HM Coroner Darren Stewart OBE 
Area Coroner for Suffolk 
By email 

4 March 2024 

Dear Mr Stewart 

East of England Ambulance Service NHS Trust 
Whiting Way 
Melbourn 
Cambridgeshire 
SG8 6NA 

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. 

Yours sincerely, 

Chief Executive

Darren Stewart OBE 
Coroner area of Suffolk 
The Coroner’s Court and Offices 
Beacon House, Whitehouse Road 
Ipswich  
IP1 5PB 

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

11 March 2024 

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 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 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. 

Yours sincerely, 

2 Clinal Reference Groups are a source of expert clinical and professional guidance and oversight.  

 
 
 
 
 
 
 
 
  
 
 National Medical Director