Jade Griffiths-Jones

Our Ref: PFD – 24-06-03 - GRIFFITHS JONES  

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

By email: 

Dear Ms Brown,  

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

 13 June 2024 

Thank you for your letter of 17 April 2024 to the Secretary of State for Health and Social Care 
, about the death of Jade Marie Griffiths-Jones. I am replying as Minister with 

responsibility for urgent and emergency care.  

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mrs Griffiths-
Jones’ 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  that 
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  at  the  West  Midlands 
Ambulance  Service  (WMAS)  University  NHS  Foundation  Trust,  and  the  hospital  handover 
delays that they  experience.  You  have appropriately  shared your report  and concerns  with 
NHS England and Birmingham Integrated Care Board who are best placed to respond on the 
specific action being taken locally to improve ambulance response and handover times.  You 
also  shared  your  report  with  the  Care  Quality  Commission  who  I  note  inspected  WMAS  in 
February 2024 and, while rating the trust good overall, raised the need to improve response 
times. 

As the Minister responsible for urgent and emergency care services, I recognise the significant 
pressure the NHS is facing and the impact of 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 targets for this 
year for a minimum of 78% of patients being admitted, transferred, or discharged within four 
hours by March 2025, and to reduce Category 2 ambulance 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: NHS England » Urgent and emergency care recovery plan year 2: 
building on learning from 2023/24 

Your  report  highlights  that  WMAS  were  under  high  demand  at  the  time  of  the  incident.  A 
primary aim of the 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. 

1 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 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.    

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.    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.  £1.6 
billion  of  funding  was  also  made  available  over  two  years  to  support  the  NHS  and  local 
authorities to ensure timely and effective discharge from hospital, helping to free up beds and 
reduce long waits for admission from A&E.  

At a national level, we have seen improvements in performance. Since January 2023, national 
average A&E 4-hour performance has improved from 70.8% in 2022/23 to 72.1% in 2023/24. 
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 27%. WMAS average Category 2 response times were over 12 minutes 
faster in 2023-24 compared to the previous year, a 25% reduction. 

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

Yours,  

2

8th Floor  
Alpha Tower  
Suffolk Street 
Queensway 
Birmingham  
B1 1TT 

Telephone: 

26th June 2024  

Via email : 

Miss Emma Brown  
Area Coroner for Birmingham and Solihull  
50 Newton Street  
Birmingham  
B4 6NE  

Dear Miss Brown  

Inquest Relating to the Death of Mrs Griffiths-Jones on 04/06/23 - Response to Regulation 28 Report 
to Prevent Future Deaths 

I write in response to the Regulation 28 Report made by you following the inquest into the death of Mrs 
Griffiths-Jones. 

Firstly, on behalf of NHS Birmingham and Solihull,  we extend our sincere condolences to the family and 
friends of Mrs Griffiths-Jones. 

NHS Birmingham and Solihull (BSOL ICB) has carefully considered the concerns raised within your report 
to prevent future deaths, specifically relating to your concern that: 

•  Death was due to natural causes in combination with a delay in ambulance attendance arising from 

increased demand for ambulances and significant hospital delays. 

•  Aside  from  seeking  funding  to  recruit  further  paramedics  and  increase  ambulance  numbers            

alongside continued monitoring and learning there is nothing West Midlands Ambulance Service 
can identify that they can do to improve the situation further. 

•  The  availability  of  ambulance  crews  is  continuing  to  be  compromised  by  delays  at  hospitals             

resulting in delays in response times which creates a risk to the life. 

All  partners  acknowledge  the  risk  posed  for  citizens  awaiting  an  ambulance  response  for  longer  than 
deemed safe within a community setting. As you outline, this can be caused by various factors including 
an increase in demand, the number of crews on duty within the ambulance trust and the productivity of 
these  crews.  This  latter  factor  is  influenced  by  how  much  time  the  crews  spend  outside  of  hospitals                 
awaiting  handover  of  their  patient,  although  other  factors  also  contribute.  It  is  also  acknowledged  that, 
although there are significant mitigations in place to prevent harm for those cared for in the back of an 
ambulance on a hospital site, remaining in the back of an ambulance at a hospital site is not without clinical 
risk, and is also a poor experience of care for the individual affected.  

 
 
 
        
 
 
 
 
 
 
 
 
 
 
 
 
 
 This letter summarises the way that partners across NHS BSOL  are working together to reduce delays in 
handover at hospitals and thus to reduce any potential harm to those awaiting an ambulance response 
within our community.  

It  should  be  noted  that  the  current  performance  metric  specified  by  NHS  England  is  that  category  2              
response times should be an average of 30 minutes and this has been included in our 2024/25 operational 
plan  for  the  NHS  locally  and  by  West  Midlands  Ambulance  Service  (WMAS).      The  average  monthly         
category 2 response time for BSOL across 2023/24 was 37 minutes and 56 seconds which is above the 
national standard of 30 minutes. This has continued to improve over the last few months as illustrated in 
the graph below.  

On  a  day-to-day  operational  level,  partners  within  BSOL  providing  emergency  care,  work  closely  with         
colleagues  at  WMAS  to  ensure  that  care  provided  as  a  whole  emergency  partnership  is  as  safe  as            
possible. The BSOL System Co-ordination Centre (SCC) co-ordinates interactions with a ‘battle rhythm’ 
of partner meetings, but individual partners, especially University Hospital Birmingham NHS Trust (UHB) 
and WMAS colleagues are in frequent and regular contact to enable best working together. Although at 
times  all  parties  can  be  managing  significant  risks  within  their  own  provider  footprint,  there  is  a                    
well-developed understanding of the concept of risk equalisation, where one provider will need to take on 
extra risk associated with a greater risk within another provider. The number and length of category 2 waits 
are  a  well  understood  marker  of  such  community  risk  with  professional  and  respectful  co-operation  to 
reduce wherever possible.  

Measures to reduce ambulance handover delays are multifaceted and are distributed across the patient 
pathway.  They fall into the categories described below: 

•  Reducing health care demand by enabling self-care. 

•  Provision  of  effective  alternatives  for  public  access  to  prevent  Emergency  Department  (ED)             

attendance with signposting. 

•  Provision of effective alternatives for health care professional access to prevent ED attendance. 

•  Effective management within UHB to reduce ED overcrowding. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Prompt and effective discharge processes from all providers to final destination. 

In addition, measures for the ICS to implement are summarised within NHS England » Delivery plan for 
recovering urgent and emergency care services.  

Each provider oversees the pathways that they deliver within their own governance frameworks. However, 
to function effectively the urgent and emergency care pathways have to work as a whole system.  Changes 
in capacity in any part of this complex programme can have effects elsewhere, and as discussed, there 
are occasions where risk sharing has to occur to ensure that the risk of harm is equalised, where possible, 
across all pathways.  

For this reason, oversight is via a UEC Delivery and Improvement Board which is chaired by the ICB Chief 
Delivery Officer with senior representation from all system partners. This Board provides integrated system 
leadership to set and deliver the Urgent and Emergency Care Strategy, with a focus on equity of access 
and system efficiency. 

Where provider performance metrics are a cause for concern these are reviewed weekly within the ICB 
System Oversight Group, along with appropriate change  programmes with trajectories  for   improvement.  
Quality concerns associated with UEC pathways are again reviewed via individual provider governance 
arrangements with ICB agreed metrics. These are discussed monthly within an escalation pathway to the 
System Quality Group and Quality Committee, where all long ambulance waits and excessive ED stays 
are discussed and escalated to the ICB Board along with mitigations to prevent harm and improvement 
plans.   Operationally, individual providers have in place a daily rhythm that oversees the efficient, effective 
and  safe  delivery  of  care  within  their  provision. This  continues  into  out-of-hours  with  senior  managerial 
input. The ICB hosts the SCC, which holds full accreditation status from NHS England in compliance with 
the national SCC specification. The team are responsible for co-ordinating the system-wide response to 
pressure  points,  such  as  ambulance  handovers  and  increases  of  activity  in  EDs,  and  supporting                    
interventions  in  all  pathways.  They  have  access  to  a  wide  range  of  data  to  enable their role  and  bring 
system partners together throughout the day, and into the out-of-hours period, to ensure joined up problem 
solving, effective flow and maintenance of safety.  

WMAS is not directly commissioned by BSOL, but by the Black Country ICB on behalf of the West Midlands 
ICBs, with BSOL as associate commissioners. As such BSOL contributes to discussion on performance 
and  quality  via  established  routes  with  Black  Country  colleagues.  Operationally,  however,  WMAS                
colleagues are very integrated into BSOL provision and daily oversight rhythm. This not only includes the 
paramedic crews themselves, but presence of a senior co-ordinating role, the Hospital Ambulance Liaison 
Officer  (HALO), and until recently provision within UHB with Ambulance Decision Areas (as below).  The 
overall  objective  of  the  HALO  service  is  to  facilitate  the  handover  of  patients  presenting  at  ED  by                 
ambulance,  in  a  clinically  safe,  effective  and  efficient  manner,    thus  enabling  crews  to  turnaround                  
ambulances  in  readiness  to  respond  to  other  emergency  calls.  This  provision  reduces  the  build-up  of                
ambulance downtime at ED sites. 

Senior operational colleagues are also involved in SCC calls to ensure that the ambulance resource is 
deployed as effectively as possible.  

Reducing health care demand by enabling self-care 

We routinely share important messages with our local communities and general public, encouraging them 
to  make  the  best  possible  choices  when  it  comes  to  seeking  care.  This  aims  to  reduce  pressure  on                  
emergency departments and other urgent care services. These messages are delivered through channels 
including social media, the media and advertising spaces in high footfall areas, all created and pushed out 
in partnership with system partners. Messages include: 

 
 
 
 
 
 
 
 
 
 
 
 •  Use of NHS 111 online and over the phone. 

•  Signposting to pharmacies and self-care options in the event of minor health concerns. 

•  Directing patients to Urgent Treatment Centres (UTC) where appropriate.  

•  Bank Holiday messages, ensuring patients are aware of available services. 

•  Emphasising the importance of vaccination as a preventative measure, both for winter illnesses 

and childhood diseases. 

•  Sharing national campaign messaging provided by NHS England. 

Provision  of  effective  alternatives  for  public  access  to  prevent  Emergency  Department  (ED)              
attendance with signposting 

Access  to  general  practice  has  been  a  significant  improvement  focus  for  the  ICB.  A  system  wide                   
improvement  programme  has  supported  practices  in  making  it  easier  for  patients  to  access  care  –                
including  improved  telephony  systems.  There  are  now  approximately  15%  more  GP  appointments                
available than in 2019, with some appointments routinely offered at weekends and evenings. Practices 
have also been working together to provide additional care in trials of ‘locality hubs’.  

NHS 111 is the main portal for access of NHS services out-of-hours, but can also be accessed in-hours if 
required. There have been an average of 1,310 calls per day over the last 12 months, with 535 of these 
calls being ‘in-hours’ and 775 calls being classed as ‘out-of-hours’. 22% of the calls to 111 are referred 
onto integrated urgent care/ED, 17% of calls are referred to primary care, 15% to a UTC and 13% require 
an ambulance to be arranged. Just over 18% of these calls require no onward referral. Call answering time 
is on average 60 seconds with 6.98% of calls abandoned. In a similar manner to WMAS services, BSOL 
ICB do not directly commission NHS111 services, but work closely as associate commissioners with Black 
Country ICB who commission this service on behalf of the West Midlands with Derby and Derbyshire ICB 
for the Midlands Region.  

BSOL has six UTCs across the footprint; these can be accessed either by walking-in or via direction from 
NHS 111. They provide an alternative pathway away from ED for those patients who require swift medical 
attention with urgent but non-life-threatening conditions. The UTCs can also offer clinical telephone advice 
to ambulance crews on the scene and can accept conveyances when and where agreed. On average, 
714 patients have been treated daily within UTCs over the last 12 months. A full review of UTC provision 
was instigated in May 2024 to ensure it meets the needs of both our local population and new national 
guidance published in October 2023.  

The ‘Pharmacy First’ Service commenced on the 31st January 2024 and enables community pharmacists 
to complete episodes of care for patients without the need for the patient to visit their GP.  Across BSOL 
93% of pharmacies have registered to provide the service which includes referrals to community pharmacy 
for  minor  illnesses,  previously  commissioned  as  Community  Pharmacist  Consultation  Service  (CPCS), 
and seven new clinical pathways which include uncomplicated urinary tract infection, shingles, impetigo, 
infected insect bites, sinusitis, sore throat and acute otitis media.  

Provision of effective alternatives for health care professional access to prevent ED attendance 

The Urgent Community Response (UCR) team, provided by Birmingham Community Health Care Trust 
(BCHC) and UHB community provision, provides urgent care for people in their homes, helping to avoid 
hospital attendance. Referrals can be made directly by GPs and there are regular contacts with WMAS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 each day to divert patients to this pathway if appropriate. There are in the region of 60 referrals a day for 
UCR. We are currently reviewing the service offered to ensure that as many patients as possible can be 
treated safely by the team.  Patients can also be admitted to the frailty virtual ward, here a patient can 
receive close monitoring in their own home with consultant oversight if required. 

‘Call before you convey’ is a direct service available to WMAS colleagues whilst with the patient in their 
own  home,  offering  different  pathways  to  use  where  appropriate,  other  than  hospital  attendance.  This 
service is primarily aimed to support patients over the age of 75 years, offering diversion into the UCR or 
wider community services. Since the commencement of this service in December 2023 there have been 
an average of just over 65 calls per week equating to nearly 10 patients per day.  

For  those  with  mental  health  needs,  where  there  is  no  physical  health  need  to  address,  discussion  is 
facilitated directly with mental health provision to determine the best way to address the care required, 
with ED avoidance where at all possible.  

Effective management within UHB to reduce ED overcrowding  

Whilst  a  number  of  initiatives  are  being  undertaken  across  the  NHS  to  assist  in  reducing  delays  and          
congestion  within  EDs,  we  have  set  out  below  an  example  of  a  number  of  initiatives  that  have  been             
implemented at UHB with the aim to reduce congestion in the ED.  

The  Rapid  Assessment  and  Treatment  (RAT)  team  assess  patients  arriving  by  ambulance  on  arrival,         
organise  diagnostic  tests  and  initiate  treatment.  In  the  event  that  there  is  a  lack  of  flow  out  of  the                    
assessment  area,  the  team  undertake  the  same  process  on  the  ambulance  in  order  to  reduce                        
delays.   Those  patients  who  are  sufficiently  mobile  and  fit  to  wait  in  the  main  seated  waiting  area  are 
directed there to reduce demand for majors cubicles and thus rapidly release the paramedic crew back 
into the community.    

An escalation process operates which makes use of defined areas within ED to accommodate patients at 
times of surge in demand. Staff are assigned to the area to maintain safety and the area is stood down 
once sufficient capacity has been released. 

The ED have a range of services they can refer into at the point of triage. The most frequently utilised of 
these  are  the  on-site  primary  care  service  and  the  Same  Day  Emergency  Care  (SDEC)  service.  The        
primary care service has capacity for around 250 patients a day (66 at QEH) across the three UHB ED 
sites,  typically  presenting  with  a  minor  illness.       The  SDEC  service  treats  ambulant  patients  on  an            
emergency  day  case  basis  in  order  to  rapidly  diagnose  and  commence  treatment  for  a  wide  range  of 
presentations.  Typically 39%  of  admitted  patients  are  cared  for  in  this manner  at the QEH.  The Frailty 
SDEC and Emergency Observation Units are also available to the triage team.   

A clinical site integrity team co-ordinates the clinical movement of patients across each site at UHB. Key 
tasks  include  the  allocation  of  patients  to  available  capacity  to  ensure  optimal  utilisation  and  the                 
management  of  the  ‘medical  push’  model  whereby  patients  waiting  admission  are  transferred  to  the            
allocated ward in advance of planned discharges leaving the ward, thus reducing the occupancy of the 
ED. The team are in frequent dialogue with all clinical specialities to co-ordinate discharges, prevent the 
spread  of  infections  and  ensure  site  safety  is  optimised  at  all  times.  This  team  also  chair  regular  site         
integrity meetings with all clinical areas to ensure any operational issues are allocated to the appropriate 
team for timely resolution.  

A key priority for all clinical specialities is the reduction of length of stay within the acute setting. A range 
of  improvement  activities  are  in  train  to  ensure  all  specialities  achieve  or  surpass  benchmarked                   

 
 
 
 
 
 
 
 
 
 
 
 
 performance levels. With emergency demand increasing each year, this activity is essential to ensure all 
patients can be accommodated in an appropriate timescale. 

Prompt and effective discharge processes from all providers to final destination 

A single transfer of care hub approach was implemented by UHB, BCHC, Birmingham City Council and 
Solihull Metropolitan Borough Council in May 2024  to improve the flow of patients out of the acute hospital 
and into community services. The new process enables fewer handoffs between teams and will enable 
hospitals to ‘free up’ beds earlier, and therefore, admit patients from ED in a more timely way. 

The package of measures set out above demonstrate the focus of the NHS and wider partners locally in 
addressing issues across the urgent and emergency care pathway within the resources that are available. 
The is important as nationally NHS England also provided WMAS with additional resources in last financial 
year (£24m) on a recurrent basis to support additional ambulance crew hours on the road and the best 
use of resources required for ambulance handover delays to be minimised.  

Yours sincerely   

Chief Executive

Emma Brown 
The 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 

31 May 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Jade Griffiths-Jones who 
died on 4 June 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 
2024 concerning the death of Jade Marie Griffiths-Jones on 4 June 2023. In advance 
of responding to the specific concerns raised in your report, I would like to express my 
deep condolences to Jade’s family and loved ones. NHS England would like to assure 
the family and the coroner that the concerns raised about Jade’s care have been taken 
into account and reflected upon.   

The report raised concerns around the demands on West Midland Ambulance Service 
and  hospital  handover  delays  and  how  ambulance  response  times  have  been 
impacted  by  this.  NHS  England  recognises  the  significant  pressure  on  ambulance 
services  since  the  COVID-19  pandemic.  Ambulance  services  have  seen  longer 
response  times  across  all  categories  than  before  the  pandemic,  as  well  as  issues 
associated with handing over ambulance patients in a timely way at some NHS Trusts. 
NHS  England  prioritised 
improving  ambulance  performance  during  2023/24, 
supported by the Delivery plan for recovering urgent and emergency care services, 
published in January 2023.  

The  plan  outlined  key  actions  to  recover  and  improve  urgent  and  emergency  care 
services, including: 

• 
• 

improving ambulance response times; 
increasing  ambulance  capacity  through  growing  the  workforce  (for  example, 
increasing clinical capacity in control rooms); 

•  alongside  broader  system  actions  to  improve  flow  through  hospitals  and 

reducing handover delays; 

•  speeding up discharges from hospitals; 
•  expanding new services in the community. 

These key actions should help ambulance crews to get back on the road to the next 
waiting patient more rapidly.  

We understand ambulance response times have not returned to pre-pandemic 
levels, however, there have been improvements in ambulance response time targets 
nationally during 2023/24. The 2023/24 year-end Category 2 mean was 36 minutes 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 23 seconds which is 13 minutes 37 seconds lower than 2022/23. For 2024/25, the 
Delivery Plan continues to focus on the improvement of ambulance Category 2 
response times. Ambulance services are expected to maintain the increases in 
capacity achieved throughout 2023/24, alongside the continued development of 
alternative referral pathways (e.g. urgent community response) to ensure that 
patients receive timely and high-quality care. 

Handover  delays  have  reduced  nationally  over  2023/24  but  still  show  a  significant 
issue to achieving increases in ambulance service capacity, particularly within certain 
geographical areas.  Targeted handover improvement work (for the acute trusts with 
the  highest  amount  of  handover  delays)  has  been  undertaken 
throughout 
2023/24.  Hospitals have worked collaboratively with ambulance services and the NHS 
England Regional teams to ensure patients are able to be handed over as quickly as 
possible. This includes utilising Fit 2 Sit for patients who can safely sit on a chair (rather 
than a hospital trolley), and direct referrals to Same Day Emergency Care and Urgent 
Treatment Centres. 

Improving  ambulance  handover  delays  is  the  responsibility  of  all  providers, 
commissioning  bodies  (Integrated  Care  Boards  (ICBs))  and  regulators.   This  year 
(2024/25)  NHS  England,  through  regular  assurance  and  planning  rounds,  are 
engaging with ICBs on a weekly basis until assurance has been given that everyone 
is  working  to  reduce  emergency  department  crowding,  improve  acute  front  door 
services and release the ambulance service/s within their commissioned frameworks 
for 2024/25.  In addition, throughout 2024/25 further work will be done to enhance and 
drive further efficiencies in acute patient flow, avoidable attendance for the frail and 
elderly emphasising same day care and care closer to home as a priority and this will 
aim  to  further  improve  the  quality  and  standard  of  care  across  the  emergency 
unscheduled care pathway.      

Within the Midlands region, the ambulance contract oversight is managed via a joint 
commissioning model, with regular system review meetings held by Derbyshire (East 
Midlands  Ambulance  Service)  and  Black  Country  (West  Midlands  Ambulance 
Service),  and  NHS  England  Midlands  region.   The  system review  meeting  explores 
service  delivery,  concentrating  upon  the  support  needed  to  improve  efficiencies, 
response standards, quality of care and the improvements needed to address the Care 
Quality  Commission’s  (CQC)  Regulation  12  for  Safe  care  and  treatment.    It  is 
recognised through the joint commissioning model, and by East and West Midlands 
ambulance  services  that  operational  productivity  has  fallen  (post  pandemic).  Both 
West  Midlands  and  East  Midlands  have  improved  the  position  greatly  throughout 
2023/24, but also recognise that there is further work to be done. I would also like to 
provide  assurance  that  the  Midlands  Regional  Director  has  been  sighted  on  and 
reviewed your report and response.  

I would also like to provide further assurances on national NHS England 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 preventable deaths are shared across the NHS at both 
a national and regional level and helps us 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,  

National Medical Director