Donna Smith

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

26 April 2024 

Clare Bailey 
Senior Coroner 
Middlesbrough 
Town Hall 
Albert Road 
TS1 2QJ 

Dear Ms Bailey,  

Thank you for your letter of 22 January 2024 to the Secretary of State for Health and Social 
Care  Victoria  Atkins,  about  the  death  of  Mrs  Donna  Smith.  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. I would like to assure you that the Department is mindful of 
the  statutory  responsibilities  in  relation  to  prevention  of  future  deaths  reports  and  we  are 
prioritising responses as a matter of urgency. 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  Mrs Smith’s 
death and I offer my sincere condolences to her family. I am grateful to you for bringing these 
matters to my attention.  

Your report raised concerns about the clinical decision support system (NHS Pathways) used 
by the North East Ambulance Service NHS Foundation Trust (NEAS) in responding to 999 
calls.  In particular, a concern about the detection of a worsening patient condition and the re-
categorising of calls from a Category 2 ambulance response to Category 1 response.  
In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS  England  (NHSE). 
NHSE has confirmed that changes to a patients’ symptoms or status during a 999 call, or on 
any subsequent 999 call, should prompt a reassessment of the relevant symptoms.  Health 
Advisors are trained to recognise where presenting symptoms change, and the NHS Pathways 
system  has  functionality  within  it  to  allow  changes  to  previous  answers  to  reach  the 
appropriate  disposition.  You  have  also  shared  your  report  and  concerns  with  NEAS  who  I 
understand have provided you with a comprehensive response following their review of the 
specific circumstances in this case and the action being taken locally to improve ambulance 
response times. 

More broadly, as the Minister responsible for urgent and emergency care services, I recognise 
the pressures ambulance services are facing and the impact of waiting times for patients. Last 
January we published our Delivery plan for recovering urgent and emergency care services to 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
    
 
 drive sustained improvements in urgent and emergency care waiting times.  This includes the 
aim to reduce Category 2 ambulance response times to 30 minutes across 2024/25.  

Your report highlights that NEAS were under high demand at the time of the incident. A primary 
aim of our Delivery plan is to boost ambulance capacity. Ambulance services received £200 
million of additional funding in 2023/24 to expand capacity and improve response times, and 
we are maintaining this additional capacity in 2024/25. This is 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.    

At a national level, we have seen significant improvements in performance this year 
compared to last year. For 2023-24, year to date (April-February) average Category 2 
ambulance response times were almost 15 minutes faster compared to the same period last 
year, a reduction of over 28%. NEAS average Category 2 response times were over 12 
minutes faster when compared to the same time period last year, a reduction of over 25%.  

However, I recognise there is still more to do to reduce response times down further and 
back towards pre-pandemic levels – However, I recognise there is still more to do to reduce 
response times further and back towards pre-pandemic levels – improving NHS services and 
reducing waiting times is a key priority of this Government. 

I hope this response further reassures you of the work undertaken. Thank you for bringing 
these concerns to my attention.  

 Yours,  

HELEN WHATELY

Strictly Private and Confidential  
Ms Claire Bailey 
Senior Coroner 
His Majesty's Coroner for Teesside  
The Coroner's Service 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

Date: 11 March 2024 

Dear Ms Bailey, 

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Inquest into the death of Donna Georgina Smith  

Regulation 28 – Report to prevent future deaths  

I am writing in my role as Chief Executive of North East Ambulance Service NHS Foundation 
Trust  ("NEAS")  and  in  response  to  the  Regulation  28  Reports  for  the  prevention  of  future 
deaths as issued by you following the inquest into the tragic death of Donna Georgina Smith.  
I am aware that you issued 2 separate Regulation 28 Reports, dated 18 January 2024 and 22 
January 2024, to NEAS and the Rt Hon Victoria Atkins MP the Secretary of State for Health 
and Social Care.  

I have opted to write one response to cover the concerns listed in the reports as I believe they 
are interlinked and avoids any duplication in response.  

The matters of concern listed in your report are: - 

Report 1 dated 18 January 2024 

1.  The computer programme and algorithms do not detect a worsening condition and do 

not prompt or indicate re-classification of a call from Category 2 to Category 1. 

Report 2 dated 22 January 2024 

1.  The call handler did not detect a worsening condition and did not escalate the call from 

a Category 2 to a Category 1. 

2.  The  methods  of  detecting  worsening  conditions  in  existing  Category  2  calls  are  not 

sufficiently robust (dispatch clinician and numerous call condition). 

3.  The  Category  2  call  target  (18-minute  average  response  and  95th  percentile  a  40- 
minute response) was breached and the ambulance arrived 1 hour and 6 minutes after 
the first call.  

We will address each point you have raised in your matters of concern below: - 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Report 1 dated 18 January 2024. 

1.  The computer programme and algorithms do not detect a worsening condition and 
do not prompt or indicate re-classification of a call from Category 2 to Category 1. 

The computer programme and algorithm used by NEAS, and other ambulance services 
across  the  country,  is  the  NHS  Pathways  telephone  triage  system  which  is  a  clinical 
decision support system (CDSS) supporting the remote assessment of callers to urgent 
and  emergency  services.  The  NHS  Pathways  system  is  widely  used  in  the  following 
settings: 

  NHS 111 (ambulance services including NEAS) 
  999 (ambulance services, including NEAS) 
 
  NHS 111 Online 
  To assist in the management of patients presenting to urgent care or emergency 

Integrated Urgent Care Clinical Assessment Services 

departments 

The system is owned by the Department for Health and Social Care and delivered by the 
Transformation Directorate of NHS England. NEAS, as a service commissioned by NHS 
England and host system suppliers enter into licences with the Secretary of State for Health 
and Social Care, allowing them to embed NHS Pathways within their products. The system 
is  maintained  by  a  group  of  experienced staff most  with  an  urgent  and emergency  care 
background. All the clinical authoring team are registered, licensed practitioners. 

To this extent NEAS have limited ability to fully respond to this specific concern and will 
defer  to  the  response  via  the  Secretary  of  State  for  Health  and  Social  Care.  We  will  of 
course fully liaise with our colleagues in NHS England to provide any additional information 
that  will  aid  their  understanding  of  the  concerns  as  a  result  of  the  inquest.  NEAS  are 
members of a national NHS Pathways User Group and feed concerns into an issues log 
which is used to consider learning and system development/improvement.  

Report 2 dated 22 January 2024. 

1.  The call handler did not detect a worsening condition and did not escalate the call 

from a Category 2 to a Category 1. 

In respect to this concern, the NEAS investigation concluded that the call handler managed 
the  call  correctly  and  followed  the  NHS  Pathways  system  and  generated  a  Category  2 
ambulance response. This is the highest level of response for a patient who is severely 
unwell but conscious and breathing and in line with the Ambulance Response Programme 
(ARP).   

There  are  four  categories  of  ambulance  response,  with  the  timeframe  for  arrival  set 
nationally as part of the Ambulance Response Programme (ARP): 

  Category 1 responses aim to arrive within 7 minutes, but on 90% of occasions no 
later  than  15  minutes.  This  is  the  highest  level  of  emergency  response  and  is 
appropriate  for  patients  with  immediately  life-threatening  presentations  (for 
example, patients who are unconscious or not breathing).   

  Category 2 responses aim to arrive within 18 minutes, or on 90% of occasions no 
longer  than  40  minutes.  This  category  is  for  serious  conditions  requiring  rapid 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 
 
 
 
 
 assessment  and/or  urgent  transport  (for  example,  chest  pain/suspected  heart 
attack, or stroke symptoms with an onset within the previous 4 hours).  

  Category  3  responses  are  a  two-hour  target  and  are  appropriate  for  urgent 
conditions  which  are  not  immediately  life-threatening  (for  example  non-life-
threatening injury from a fall). 

  Category 4 responses are non-blue light response and are the lowest priority. Most 
of these calls will be dealt with through hear and treat or see and treat. The National 
Standard is for 90% of patients to have received a response within 3 hours. 

During periods where there is more demand for ambulances than we have ambulances 
available to attend, we will prioritise the responses according to the categories above and 
will divert travelling vehicles to patients of a higher clinical priority who require more urgent 
assessment or life-saving interventions. 

Call handlers do not have the ability to choose the system generated response as this is 
achieved  via  the  system  algorithms.  Whilst  a  clinician  can  upgrade  an  ambulance 
response  based  on  a  clinical  assessment,  in  this  case  the  fact  the  patient  was  still 
breathing, and conscious would not have generated a Category 1 response. I understand 
this was covered in evidence heard during the inquest and the findings within the NEAS 
investigation. We will defer further commentary on this point as it will be considered in the 
response by the system owners, NHS England via the Secretary of State for Health and 
Social Care.  

2.  The methods of detecting worsening conditions in existing Category 2 calls are not 

sufficiently robust (dispatch clinician and numerous call condition). 

Clinicians working in the Emergency Operations Centre (EOC) have the ability to upgrade 
a disposition following their clinical assessment, supported by the NHS Pathways system 
and underpinned by their clinical knowledge. In this case the investigation identified that 
the clinician had not sufficiently probed the responses provided.  

The clinician’s call review highlighted that the call was below the required standard due to 
insufficient probing of the patient’s symptoms within the following areas:  

1) The clinician did not ask if the patient was conscious.  
2) The clinician did not ask for the skin temperature to be rechecked.  
3) There was no probing regarding the level of breathing when described as shallow.  
4) There was no probing regarding past medical history.  
5) The clinician asked no questions about the chest pain.  
6) It is unsafe to ask a patient having a possible MI to be taken to hospital by car.  
7) There was no probing into why the family could not get the patient out of the chair.  
8) The clinician did not ask why the fire brigade were attending.  
9) Attitudinal concerns  

In the event that information was available pertaining to the above concerns, this would 
have aided clarification of a peri arrest patient. However, had the patient been conscious, 
still  warm  to  touch  and  with  regular  breathing  the  resultant  disposition  would  not  have 
reached  a  higher  priority  (Category  1).  Incidentally,  information  available  on  the  ePCR 
outlined  that  the  patient  was  alert  and  orientated  upon  arrival  therefore  the  Category  2 
disposition, at the time of ambulance arrival, was appropriate.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 Whilst not directly linked with this case, we are writing a procedure for EOC clinicians to 
provide guidance for deteriorating patients. The procedure is not yet finalised given the 
complexities and balance of not overwhelming the system with higher priority ambulance 
responses.  The  risk  with  the  latter  is  that  we  would  create  potential  risk  for  patients 
categorised as Category 2 and Category 3, ultimately leading to delayed responses. The 
underpinning  principles  are  those  achieved  by  using  the  NHS  Pathways  system  and/or 
other algorithm-based triage tools and achieving the Ambulance Response Programme 
response targets.  

3.  The  Category  2  call  target  (18-minute  average  response  and  95th  percentile  a  40- 
minute response) was breached and the ambulance arrived 1 hour and 6 minutes 
after the first call.  

I am aware that the inquest touched upon the pressures faced by the health and social 
care  system  and therefore the  inclusion  of  the  Secretary  of  State for  Health  and  Social 
Care in the Regulation 28 Report. The following details provide an overview of the work 
being undertaken by NEAS and the action plans we are working towards. This includes 
contracting negotiations to secure additional funding to help improve service delivery and 
ambulance response times.  

The  Trust  has  developed  and  are  working  within  a  detailed  action  plan  to  improve  our 
Category  2  ambulance  response,  which  links  with  our  other  Ambulance  Response 
Programme (ARP) targets. The action plan is split into three main categories, ‘Increase 
‘Improved  Operational 
‘Decrease  Response  Demand’  and 
Response  Capacity’, 
Efficiency’. 

To  provide  some  current  context,  the following  information  provides  an  overview  of  our 
performance in December 2023. We have extracted this information from a performance 
exception report which was shared with the Trust’s Performance and Finance Committee 
on 23 January 2023. 

  Performance for December 2023, while challenged shows significant improvement 
against December 2022, despite significant increases in call demand, Emergency 
Operations Centre (EOC) clinician demand and face to face incident demand. 
  Response times for C1 and C4 have remained stable with increases noted for C2 
and  C3,  as  expected. Only  C1  90th  Percentile  achieved  the  national  standard  in 
December 2023. Increased demand and deteriorating handover performance have 
been the main contributing factor to increased response times in December 2023. 
  Benchmarking data shows that NEAS is performing well compared to the rest of 
the sector. NEAS is the best performing Trust for both C1 targets and C4, with all 
other  categories  better  than  the  national  average.  For  the  year-to-date  NEAS  is 
reporting  Category  2  mean  position  at  35m  23s,  which  is  better  than  the  YTD 
national average of 36m 15s. 

  Both 111 and 999 mean call answer continues to perform well with both reporting 
special  cause  improvement,  despite  increases  in  call  demand  (999  +12%;  111 
+19%  compared  to  previous  month).  999  call  answer  achieved  the  national 
standard for a fourth consecutive month.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 
 
   EOC clinician demand significantly increased in December 2023 compared to the 
previous month (+22%), impacted by increases in 111 call demand. Despite the 
increase  in  demand  111  C3/4  validation  rate  has  continued  to  improve  and  call 
back  performance  and  ED  validations  have  remained  within  normal  limits. 
Performance against clinical KPI targets remains challenging. 

  Patient Transport Service (PTS) performance continues to flag as special cause 
concern, with only time on vehicle <60 minutes consistently achieving the standard. 
The volume of completed and aborted journeys remains high with fluctuations in 
daily demand along with impact of industrial action impacting operations. 

  C2 mean for December 2023 was 2 minutes 6 seconds better than planned at 42 
minutes  29  seconds.  Capacity  hours  (+3.1%),  average  handover  times  and 
unavailable  time  performed  better  than  planned,  despite  increased  demand 
(+4.0%) and on job time.  

The report progresses to provide updates against the Category 2 improvement action plan, 
in relation to the actions to reduce demand, the following updates were provided: 

  Rotational [between duties on the road and duties in EOC] paramedics recruited 
into  EOC  to  support  C2  Segmentation  [further  clinical  validation  of  C2  cases  to 
identify cases that are not C2. This protects resources for C2 patients whilst still 
caring  for  none  C2  patients]  and  999  C3/4  validation  are  operational.  C2 
Segmentation is now live, with early data indicating this is having a positive impact 
on validation outcomes. 

  New Health Care Professional (HCP) process went live on 11 September 2023 to 
support identification of appropriate response categories. Early data shows that we 
have  seen  a  significant  increase  in  Level  3  HCP  requests,  while  overall  HCP 
demand  has  not  shown  signs  of  reducing.  Work  is  being  planned  in  the  wider 
system to further consider actions which could be taken to address HCP demand.   

The actions to increase capacity update included: 

  Continued  delivery  of  Paramedic  and  Clinical  Care  Assistant  (CCA)  recruitment 

plans, remain on track. 

  All additional third-party hours funded by additional NHS England investment have 

now been secured.  

  Additional  shifts  are  being  offered  as  overtime  to  boost  capacity,  with  targeted 

overtime shifts incentivised over the Christmas period.  

  Options to extend operating hours within NEASUS and support improved vehicle 
availability are being reviewed. Bi-weekly operational fleet meeting is now in place 
to provide clearer oversight and scrutiny to vehicle shortages to enable us to work 
better with NEASUS and be more proactive in identifying hot spots. (NEASUS is a 
wholly owned subsidiary of NEAS, providing fleet and other specialist services) 

  Full review of all Alternative Working Duties completed. 
  Buy-back scheme for annual leave has been implemented. 
  Cleveland Fire Service are now responding to Category 1 incidents in the Loftus 

area. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 
 
 
 Action to improve efficiency update included: 

  Task  and  Finish  group  established  to  focus  on  releasing  time  including 
improvement  of  processes  to  manage  downtime,  system  development  being 
progressed  to  enable  auto  clear  for  crews.  Individual  level  reports  have  been 
developed  to  support  performance  management  of  downtime.  Changes  to 
downtime codes and processes have been developed. 

  A new deployment plan for Advance Practitioners (APs) has been developed and 
trialled, which aims to increase utilisation as well as reducing conveyance rates by 
targeted deployment.  

  Action plan in place to reduce On Scene time for See and Treat incidents. 
  Operations  Co-ordination  Centre  (OCC)  is  now  in  place  providing  a  centralised 
function based on the best practice and learning from other ambulance Trusts. A 
central point which will manage any time critical matters to ensure consistency and 
clarity to both internal and external stakeholders.  

  The Trust continues to work with the ICB to support the wider system delivery of 
handover  improvement.  Additional  system  actions  have  been  implemented  to 
mitigate impact of handover times including: 2-hour handover reporting to Directors 
on-call, with 3-hour handovers escalated to ICB strategic on-call; Paramedic and 
Nurse  Emergency  Department  navigators  in  place  in  4  locations;  Hospital 
Ambulance  Liaison  Officers  (HALO)  in  place  at  James  Cook.  Development  of 
immediate handover proposal is being progressed as part of C2 extremis actions. 

The report concludes with an overview of the C2 performance forecast: 

  C2 forecast of 00:34:57 for 2023/24 has been submitted to NHS England following 
approval  by  Executive Management Group  (EMG).  This  is  an  increase  from the 
position submitted the previous month which reflects increase in forecast demand 
in Q4 2023/24 of 0.7%, a reduction in weekly vehicle hours of 0.7% impacted by 
increased CCA attrition rates and updated maximum third party hours. 

  There remains considerable risk in the forecast with January expected to be more 
challenging linked to flu peak expected to be seen mid-January and the level of 
unknown  risk  associated  with  strike  action.  Ambulance  handover  times  and 
demand also remain key risk factors: 

-  Ambulance  Handover  times:  average  handover  time  is  forecast  to  achieve 
21minutes for the year, which includes deterioration through winter in line with 
the plan. Current handover times are above forecast, with the risk that these 
will continue to deteriorate. The Trust continues to work with the ICB to support 
the wider system delivery. 

-  Levels of demand: The actions NEAS have taken internally, including deploying 
additional capacity, use of third-party providers, and category 2 segmentation 
have  given  a  benefit  in  meeting  increasing  demand,  and  maintaining  rather 
than improving performance.  

If it would be helpful, we can share a copy of the performance report for your information, 
this provides a greater level of detail in respect to the ongoing efforts the Trust is making 
to  improve  performance.  The  detailed  report  contains  supporting  data  analysis  which 
contains commercial sensitive information, but we would be happy to share this for your 
information.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 
 
 As mentioned, NEAS have a detailed Category 2 improvement action plan, the following 
detail is taken from this action plan, which we have summarised, to provide an overview of 
the actions implemented to date alongside the additional actions NEAS have identified and 
are progressing at pace. The first section relates to those actions NEAS have completed 
before progressing onto those being implemented and assessed for impact. 

1.  Dedicated dispatch officer focused on pass to Patient Transport Service calls. 

Following a Trial and identification of a clinical visibility issue with Pass to Patient Transport 
Service (PTS) approach a solution of an additional specific dispatcher was suggested and 
trialled. This has seen positive results and will be implemented for the remaining financial 
year.  This  will  support  additional  pass  to  PTS  and  reduction  of  activity  on  Urgent  and 
Emergency  crews  by  using  non-emergency  ambulance  for  transportation  where 
appropriate. 

2.  Designate a volume of Pass to Patient Transport Service (PTS) work per day and 

allocate Third Party Providers (TPP) vehicles to do this. 

Linked with point 1 above, with pass to pass to Patient Transport Service (PTS) this will 
be  co-ordinated  through  the  additional  Dispatch  desk  to  co-ordinate  PTS  resources 
supporting  Urgent  and  Emergency  crews.  As  above,  a  dedicated  dispatcher  has  been 
allocated to dispatch Third Party Provider resources. 

3.  Review Dispatch Plan on multiple resource assignments. 

We  have  analysed  data  regarding  current  responses  per  incident  against  national 
benchmarking data. Alongside a review of the deployment guidance, the analysis shows 
we are placed in the middle for responses per incident against national benchmarking.   

4.  Secure additional Patient Transport Service (PTS) support focused on weekends. 

The Patient Transport Service (PTS) management team have improved the opportunities 
for PTS staff and resources to respond to urgent and low acuity pass to PTS demand at 
weekends in addition to supporting 7-day discharge efforts at weekends. 

5.  Incentivise weekend overtime. 

Following several reviews, the use of incentivised payments over specific periods had very 
limited effect on achieving higher levels of staffing at key points. An updated report was 
received  and  considered  by  the  Executive  Management  Group  (EMG),  outlining 
recommendations to offer enhanced overtime on certain shifts of the week for a defined 
period.  This action was closed on 4 January 2024. 

6.  All Health Care Professional (HCP) calls to be a clinician-to-clinician conversation. 

The reliance of HCPs upon NEAS has been flagged to the ICB and features as one of their 
actions  regarding  demand  reduction.  Despite  NEAS’  success  triaging  HCP  calls  to  the 
correct category, there has been minimal movement of the overall volume of HCP requests 
to NEAS. There is an option for all HCP referrals to be clinically assessed on booking. This 
had  benefits  during  industrial  action,  however  it  is  not  popular  with  HCP  callers  and 
potentially  an  action  in  escalation.  NEAS  continues  to  be  an  outlier  for  HCP  activity.  
Further work is planned with the ICB to establishing how overall demand could be safely 
reduced. This specific action was closed and combined with another action to review the 
whole HCP triage process. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 7.  Review End of Shift tasking. 

The  end  of  shift  tasking  policy  was  reviewed  to  identify  opportunities  for  improved 
response  to  C2  calls  at  end  of  shift.  The  review  concluded  that  the  policy  was  clear  in 
respect to tasking crews to cases. The action was closed on 11 January 2024. 

8.  Revisit NEASUS SLA and look for increases in productive vehicle hours. 

It  was  agreed  that  a  focus  on  vehicle  availability  and  the  ability  to  flex  to  increase  the 
number  of  vehicles  available  for  overtime  and  clinical  supervision  should  be  a  priority. 
There is potential of supporting NEASUS with financial support to flex on current SLA. This 
action was closed in December 2023. NEASUS is North East Ambulance Service Unified 
solutions  and  is  a  wholly  owned  subsidiary  company  providing  fleet  management  and 
other support services to NEAS.  

9.  Secure additional overtime 

Current levels of overtime uptake is running at 5%. Experience suggests more than this is 
achievable so further work is required to test solutions to offer and secure greater levels 
of overtime uptake. A report was received and reviewed by the Executive Management 
Group (EMG) in December 2023 outlining a recommendation to offer enhanced overtime 
on certain shifts of the week for a defined period.  This action was closed. 

The  next  section  provides  an  overview  of  the  actions  which  are  in  progress  and/or  in  the 
pipeline to commence. I have not expanded the details due to the significant detail included in 
the action plan. I have not shared a copy of the action plan at this stage but would be happy 
to forward a copy if it would be beneficial. As I have mentioned above, this type of information 
is commercially sensitive as it touches upon wider health and social care system work. 

1.  Split Dispatch Desks now that have the highest volume of resource/activity. 
2.  Stop any call upgrades without consultation with a senior clinician. 
3.  Implement Clinical Navigator Role 
4.  Offload at 45 minutes 
5.  Prioritise Revalidation over 111 calls waiting for clinician input 
6.  Review of HCP triage and process 
7.  Low level of No send implemented as ‘Business As Usual’ (BAU) 
8.  Localised Targets for Geographical Areas 
9.  Auto Allocation of Community First Responders (CFRs) and Falls Teams 
10. Visibility of the Number of ‘Hear and Treat’ cases required per shift to meet the target 
11. Evaluate on scene time to establish targets, assisting Emergency Operations Centre.  
12. Reduce need for passing patient details back to GPs. 

Ongoing  work  linked  with  the  above  includes  the  following  improvements  to  help  maintain 
resource availability for Category 2 emergency response. NEAS are currently employing the 
following additional tactics. 

eVDI/daily clean trial 

We  are  implementing  a  trial  process  in  one  division  aimed  at  optimising  the  efficiency  of 
ambulance  operations  by  standardising  essential  tasks,  completion  time  and  enhancing 
communication  between  ambulance  staff  and  dispatch.  Currently,  ambulance  crews  are 
required to conduct vehicle inspections, including a drugs and equipment check, as well as 
sterilise their vehicles (known as the daily clean) at least once every 24 hours.  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 However,  the  time  it  takes  to  complete  these  tasks  varies,  leading  to  potential  delays  in 
responding  to  emergencies.  To  address  this  issue,  we  have  conducted  time  and  motion 
studies to establish a benchmark time of 20 minutes for completing these tasks. During this 
protected  period,  the  system  automatically  times  the  staff,  and  dispatch  staff  receive 
automated alerts once the 20-minute period elapses. This streamlined process ensures that 
all essential tasks are completed effectively, setting clear expectations for staff and eliminating 
the need for interpretation. By providing ambulance crews with protected time and promptly 
alerting  dispatch  staff  when  they  are  available  for  dispatch,  we  aim  to  minimise  delays, 
enhance communication, and improve overall operational efficiency. 

Staggered shift start and finish times 

In addition to optimising operational efficiency through the trial process outlined above, we are 
further  enhancing  capacity  during  break  periods  and  end-of-shift  protection  periods  by 
implementing staggered start and finish times for ambulance crews. This strategic adjustment 
ensures  a  smooth  transition  at  shift  changeovers  and  eliminates  potential  bottlenecks.  By 
staggering  start  and  finish  times,  we  effectively  stagger  break  windows  as  well,  optimising 
resource utilisation throughout the day. Moreover, we are leveraging third-party providers to 
cover bridging shifts during break and shift changeover periods. These providers seamlessly 
fill  in  gaps  in  coverage,  ensuring  continuity  of  service  and  minimising  any  disruptions  in 
emergency response. By engaging third-party providers strategically, we bolster our capacity 
during critical periods, maximising our ability to respond promptly to emergencies and maintain 
high standards of care for the community. 

Dispatch Clinical Risk Assessment Standard Operating Procedure (SOP) 

In December 2021, we implemented a Dispatch Clinical Risk Assessment Standard Operating 
Procedure  (DCRA)  aimed  at  dispatching  ambulances  to  patients  more  effectively  using  a 
clinical risk approach. This process ensures consistency and optimises resource utilisation by 
prioritising based on clinical risk rather than just the order of time. Traditionally, ambulance 
services use priority codes (C1, C2, C3, C4) to dispatch ambulances, with C2 being the most 
common  category  encompassing  a  broad  range  of  critical  conditions.  However,  our  new 
process further categorises C2 calls based on clinical risk rather than solely on the time the 
call was received. These secondary priority codes are derived from a variety of data sources, 
including mortality data, ED pre-alert data, patient outcome data, recontact data, input from 
the  NEAS  patient  safety  department,  national  policy,  and  coronial  data.  Emergency 
Operations  Centre  (EOC)  clinicians  and  dispatchers  collaboratively  review  each  C2  call, 
clinically assess it for risk, and assign a secondary code. Dispatchers then utilise a deployment 
plan to prioritise responses accordingly.  

For instance, if a clinician determines through patient assessment that an immediate response 
is necessary, they categorise the call as 'priority,' with only Category 1 calls taking precedence. 
In addition to the EOC clinician code, there is an operational code allowing lone paramedic 
responders to request immediate backup, known as ‘Red’ backup. This code supersedes C2 
cases without a sub-code and P3 to P7 sub-codes. Priority levels P3 to P7 are assigned to 
Category 2 calls based on the severity of the condition using a predetermined set of criteria. 
This system ensures that the sickest patients receive attention promptly, reducing the need 
for estimated time of arrival (ETA) calls and upgrades. By prioritising obviously sick patients, 
dispatchers  enable  clinicians  to  focus  on  undifferentiated  cases  that  may  be  suitable  for 
alternative transport or safe to wait, thereby reducing clinical risk and alleviating service-wide 
pressure. This structured approach enhances patient care and resource allocation within the 
ambulance service. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 In addition, to the above actions, NEAS have a ‘longlist’ of additional actions which are being 
considered.    Category  2  additional  actions  continue  to  be  reviewed,  refreshed  and 
consolidated  with  focused  weekly  update  sessions.  Recently,  the  Executive  Management 
Group have been informed that further work has been done on developing the extended scope 
of  the  second  phase  of  the  HCP  project  and  action  owners  relating  to  the  longlist  have 
refreshed  their  actions  with  further  work  required  on  progressing  the  actions  sitting  in  the 
clinical directorate. There has been a full review of our Alternative Working Duties policy which 
is now updated with a clear mandate that all clinicians with a minimum of four months will first 
be considered for EOC roles.  

If it would be beneficial, we can arrange to share the full details of this work with you, certainly 
for  those  actions  which  may  be  taken  forward  following  further  consideration  and  risk 
assessment.  

On a more general note, the Trust is currently in contract negotiations in respect to funding 
from  our  commissioners.  We  have  requested  additional  funding  to  enable  an  increase  in 
resources to help improve service delivery, including improving ambulance response times. I 
am aware that the contract negotiations include discussions surrounding the wider health and 
social  care  system  and  what  other  partners  can  do  to  assist  with  easing  pressures  on  the 
Trust.  Factors  such  as  hospital  handover  delays,  availability  of  other  services,  demand 
deflection  and  inappropriate  discharges  all  create  potentially  unnecessary  demand  on  the 
Trust.  This  is  not  unique  in  our  region  and  is a  challenge  faced  by  our  colleagues  in  other 
ambulance services around the country.   

In addition to the pressures on our operational crews, the funding request is to help secure 
further investment into the Dispatch function to reduce the chance of missed opportunities to 
dispatch an ambulance to patients most in need. As demand for NEAS services has grown, 
increasing  numbers  of  patients  remain  on  the  Dispatch  Stack.  With  workloads  on  each 
Dispatch  desk  growing,  NEAS  commissioned  independent  reviews  by  the  Association  of 
Ambulance Chief Executives and Operational Research in Health (ORH). The evidence from 
these reviews shows that each Dispatch desk has more resources than would be considered 
appropriate to achieve optimum performance with the resources available. A business case is 
being  finalised  for  commissioners  to  consider  as  part  of  the  2024/2025  planning  rounds.  If 
secured, this investment would support the introduction of a Critical Incident Hub which would 
increase  the  number  of  dispatch  officers,  therefore  reducing  the  number  of  resources  they 
overview/dispatch.   

I hope that this provides sufficient detail to address your concerns. I must add that some of 
the planned work is reliant upon the next round of funding negotiations, we would be able to 
provide an update on the funding negotiations as matters progress.  

I hope that this addresses the matters of concern which you have highlighted.  

Yours sincerely,  

The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).  

  
 
 
 
  
 
 
  
 Chief Executive 

Chair: Peter Strachan | Chief Executive: Helen Ray  
The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID: RX601).