Jean Walker

From Minister Helen Whately 
Minister of State for Care 
39 Victoria Street 
London 
SW1H 0EU 

 14 June 2024 

Our Ref: PFD – 24-03-20 - WALKER 

Assistant Coroner Hannah Berry 
South Yorkshire (West) 
Medico Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

By email: 

Dear Ms Berry, 

Thank you for your report of 20 March to the Secretary of State for Health and Social Care 
regarding the death of Jean Walker. I am replying as Minister with responsibility for urgent and 
emergency care services.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Walker’s 
death, and I offer my sincere condolences to her family and loved ones. It is vital that where 
Regulation 28 reports raise matters of concern these are looked at carefully so NHS care can 
be improved.  I am grateful to you for bringing these matters to my attention.  

Your  report  raised  concerns  about  ambulance  response  times  and  capacity  at  Yorkshire 
Ambulance  Service  NHS  Trust  (YAS)  as  a  result  of  handover  delays  at  hospitals.  These 
concerns were also raised directly with the responsible NHS Integrated Care Board.  

In preparing this response, my officials have made enquiries with NHS England (NHSE). I am 
informed  that  the  West  Yorkshire  Integrated  Care  Board  will  shortly  be  responding  on  the 
specific local actions being taken to support ambulance response times. NHSE has advised 
my officials that investment is being made for additional crews and fleets as well as clinical 
workforce in the Emergency Operation Centre to support decision making on the phone and 
support crews attending calls at home. Further, I understand that there is work with partners 
across the region to address handover delays including implementation of a Duty to Rescue 
protocol to release crews from hospitals to respond to immediate community emergencies.  

As the Minister responsible for urgent and emergency care services, I recognise the significant 
pressure the NHS is facing and the impact on waiting times for patients. In January 2023, NHS 
England  published  a  two  year  ‘Delivery  plan  for  recovering  urgent  and  emergency  care 
services’ which aims to deliver sustained improvements in waiting times, with a target for this 
year to reduce Category 2 response times to 30 minutes on average. An update to this plan 
has now been published, to build on learnings from the first year and to continue to support 
systems to improve performance and reduce waiting times. The plan is available at: 
https://www.england.nhs.uk/wp-content/uploads/2024/05/PRN01288_ii_Delivery-plan-for-
recovering-urgent-and-emergency-care-progress-update-and-next-steps-May-2024.pdf   

1 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 Your report highlights reduced ambulance resource in the Yorkshire region at the time of the 
incident. To support ambulance services, ambulance trusts received £200 million of additional 
funding in 2023/24 to expand capacity and improve response times. In addition, to improve 
patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to 
increase staffed core hospital beds by 5,000 compared to 2022/23 plans. 

Since publication of the plan in January 2023, there have been improvements in performance. 
At a national level in 2023/24, average Category 2 ambulance response times (including for 
serious conditions such as heart attacks and strokes) were over 13 minutes faster compared 
to the previous year, a reduction of over 27%. In the Yorkshire region, average Category 2 
response times were over 9 minutes faster compared to the previous year, a 23% reduction. 
Regarding handover delays, in April the average patient handover time in the Yorkshire region 
was 29 minutes 2 seconds. 

Yours,  

HELEN WHATELY

White Rose House 
West Parade 
Wakefield,  
WF1 1LT  
Visit: www.wypartnership.co.uk 

Twitter: @WYpartnership   

16 May 2024 

Hannah Berry  
H.M Assistant Coroner for South Yorkshire West 
Via email: 

Dear Ms Berry, 

Thank you for your letter of 21 March 2024 in relation to the Regulation 28 report to 
prevent future deaths, following the inquest into the death of Jean Walker. This was 
issued to:  

1. The Department of Health and Social Care, 39 Victoria Street, London, SW1H 
0EU  

2. The West Yorkshire Integrated Care Board, White Rose House, West Parade, 
Wakefield, WF1 1LT. 

I would like to start by offering my deepest condolences to the family of Mrs Walker 
on behalf of the NHS West Yorkshire Integrated Care Board. I am sorry for their loss. 
I hope that this letter provides reassurance of our collective commitment to delivering 
services that meet the needs of the population within Yorkshire and the Humber and 
the lessons learned. 

You asked for a response from the NHS West Yorkshire Integrated Care Board 
(WYICB) regarding the following areas of identified concern, the actions that are 
being taken and the timelines that are being taking with our system partners to put in 
place improvements. I am responding on behalf of NHS WY ICB as the lead 
commissioner of services from Yorkshire Ambulance Service (YAS) in relation to the 
following: 

•  The ambulance service was called at 0348 on 4 November 2022 and the call 
was coded as a (Category 2) call requiring a response within 40 minutes. The 
ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 
minutes after the call.  

•  There was a significant delay in handing over patients at hospitals which 
meant they had prolonged waits and were unable to respond to other 
emergency calls. 

 
    
 
 
 
 
 
 
 
 
 Background 

It is helpful for our learning to understand the wider context at the time of Mrs 
Walker’s death, to ensure that all relevant issues are considered. The winter of 
2022/23 was a period of extreme pressure across the health and care system, due to 
a number of unique factors. During this time, the ambulance service was similarly 
affected nationally, including YAS. Pressure was also evident within the wider 
healthcare system in Yorkshire and the Humber, with associated difficulties in the 
timely discharge of patients to the most appropriate care settings. During this period, 
patients and families faced delays in assessment and treatment, for which I am truly 
sorry. 

As a consequence of this, patient flow through acute hospitals was significantly 
impacted. There were some hospitals with queuing ambulances. This was all 
exacerbated by very high levels of Covid and Influenza, coming at the same time as 
a national spike in Strep infections in children, as well as high levels of staff sickness 
absence throughout all areas of the NHS.   

As a result, overall ambulance response times increased, and during November 
2022, the mean response time for ambulances (Category 2) within the South 
Yorkshire Integrated Care Board (SY ICB) area was 55 minutes and 9 seconds. I am 
sorry we were unable to provide a better service at this time. 

NHS Recovery Plans 

In January 2023, NHS England published its Delivery Plan for recovering Urgent and 
Emergency Care (UEC) services to respond to the challenges we had faced. To 
support recovery, the plan set out two key ambitions:  

•  Patients being seen more quickly in Emergency Departments: with the 
ambition to improve to 76% of patients being admitted, transferred or 
discharged within four hours by March 2024, with further improvement in 
2024/25.  

•  Ambulances getting to patients quicker: with improved ambulance response 
times for (Category 2) incidents to 30 minutes on average over 2023/24, with 
further improvement in 2024/25 towards pre-pandemic levels.  

Since April 2023, the three Integrated Care Boards (ICBs) across Yorkshire and 
Humber have worked jointly through an Executive Leadership Board (ELB) with YAS 
to agree joint priorities and to improve performance and allocate additional 
investment. This investment was aimed at recruiting additional ambulance crews, 
developing new ways of working to avoid conveyance to hospital, and investment in 
new vehicles, all of which are aimed at being able to provide a more timely response 
and meet increasing demand.  

Within the Yorkshire and Humber region there have been improvements in response 
times. For the financial year ending March 2024 the mean (Category 2) response 

 
 
 
 
 
 time had reduced to 32 minutes and 26 seconds, within SY ICB the mean response 
was 31 minutes and 45 seconds. 

Hospital Handovers and Ambulance Turnaround Times 

The correlation between handover delays at Emergency Departments and overall 
ambulance response times is widely acknowledged. Handover times vary amongst 
our acute trusts in the region. We seek to ensure the root causes are understood.  

Alongside this handover time, the full turnaround time includes how long it then takes 
ambulances to be ready to take another assignment. During the calendar month of 
November 2022, the mean ‘turnaround time’ within South Yorkshire was 58 minutes 
and 12 seconds. This is well outside the expected standards. 

The most recent calendar month of reporting (April 2024) showed that the mean 
turnaround time for ambulances had reduced to 49 minutes and 48 seconds, 
showing some improvements. Work continues to support further improvements. In 
particular, in collaboration with the acute trusts, YAS has implemented targeted 
Quality Improvement initiatives to improve handovers. This helps further reduce the 
amount of ‘lost ambulance handover time’ and allow ambulances to return to 
respond to emergency calls in a more timely manner.    

As part of operational planning for 2024/25, SYICB has set out an improvement 
trajectory for hospital handover times to be reduced to an average of 19 minutes. 
This will require continued focus on quality improvement and leadership to support 
delivery.  

Further support measures  

YAS and Sheffield Teaching Hospitals NHS Foundation Trust (and other trusts within 
South Yorkshire) have agreed a new Joint Escalation Action Plan (JEAP) for when 
system pressures increase, this plan provides specific actions that organisations 
must employ to support the improvement of ambulance handover. This is the specific 
element of the turnaround time that involves the ambulance handing over to the 
Emergency Department. 

Handover times from ambulances to Emergency Department teams in South 
Yorkshire were 39 minutes and 49 seconds during the winter period (November 2022 
to March 2023). Handover times had reduced to 32 minutes and 37 seconds 
(November 2023 to March 2024). I am pleased to report that a further reduction in 
handover times in April 2024 within South Yorkshire has been achieved with mean 
handovers within South Yorkshire being achieved in 28 minutes and 24 seconds. 

Implementation of ‘Duty to Rescue’ protocol - this protocol was introduced ahead 
of the winter period (2023/24) and is now enacted at times of significant operational 
pressure. On occasions when there are high number of ambulances waiting to 
handover patients, the protocol allows for senior clinical decision makers from YAS 
and our hospitals to agree to the rapid handover of a patient who is deemed at 
immediate clinical risk of deterioration and release an ambulance crew to attend to a 

 
 
 999 call, or one who has been awaiting conveyance and is deteriorating. The 
introduction of this protocol has been welcomed by all parties and allows for clinical 
risks to be better managed in the system. 

Alternatives to Accident and Emergency (A&E) Departments – more alternative 
pathways of care are available for use by YAS Ambulance crews or staff within the 
Emergency Operations Centre (EOC) to safely and appropriately avoid conveyance 
to hospital.  

YAS has worked with partners across the urgent and emergency care system to 
improve availability of these pathways, including through the development of Urgent 
Community Response (UCR) services. These respond to a patient in their own home 
within two hours of the call in an aim to avoid hospital attendance where appropriate, 
and also gives direct access pathways to clinicians for Same Day Emergency Care 
(SDEC) at local hospitals, which allow ambulance crews to bypass A&E for suitable 
patients and therefore improve hospital flow and ambulance turnaround.  

The EOCs have continued to invest in the clinical workforce utilising clinical 
navigators to assist in the identification of incidents suitable for an alternative 
response or which can be clinically assessed and given self-care advice. General 
Practitioners (GPs) have also been employed to both assist with remote assessment 
and also to support clinical decision making more generally to improve outcomes 
and ensure patients are directed to appropriate care relevant to their needs. 

The EOC continues to improve referral processes to other services diverting demand 
into alternative more appropriate care pathways and have recently brought online 
partners to assist with triage of Mental Health concerns. The EOC currently push on 
average 2,809 incidents per month to alternative response providers with on average 
2,392 being accepted.   

System Coordination Centre (SCC) has also been developed over the past year.  
The SCC is a central co-ordination service to providers of care across the ICB 
footprint to enable a proactive system response to operational pressures and risks 
with the aim to support patient access to the safest and best quality of care possible.  

Governance 

I can confirm this Regulation 28 – Future learning from deaths notification has been 
presented to and discussed at the YAS Clinical Quality Oversight Group to share the 
matters of concern raised across the Yorkshire and Humber region, this in turn will 
be escalated to the Executive Leadership Board which has oversight of the 
Ambulance Service in Yorkshire. 

As an ICB we maintain our shared commitment with both YAS and our partner ICBs 
within Yorkshire and Humber to ensure we are delivering safe, high-quality services 
for patients, carers and their families.  

 
 
 
 Thank you for bringing these concerns to my attention. I hope that the information 
provided in this letter offers some assurance on the improvements we have made 
with our partners, resulting improvements in patient safety and the commitment to 
continue to deliver improvements across the system. 

If you require any further information, please do not hesitate to contact me.  

Yours faithfully, 

Chief Executive 

NHS West Yorkshire Integrated Care Board        
West Yorkshire Health and Care Partnership