Sophie Hindmarsh

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

 3 July 2024 

Our Ref: PFD – 24-04-29 Hindmarsh 

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

By email: 

Dear Ms Berry,  

Thank you for your letter of 17 April regarding the death of Sophie Hindmarsh. 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 Ms Hindmarsh’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 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  by  Yorkshire  Ambulance 
Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your 
report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). 
Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care 
Board who I understand will be writing to you directly on the specific actions being taken locally 
to improve ambulance response and handover 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, 
NHSE 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: 
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  

Your report highlights that YAS were under high demand 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. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 £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. 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%. YAS 
average Category 2 response times were over 9 minutes faster in 2023/24 compared to the 
previous year, a reduction of almost 23%. In May 2024, average patient handover times in the 
YAS  region  were  28  minutes 58  seconds, the fourth consecutive month  average  handover 
times have been less than 30 minutes. 

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

Yours,  

HELEN WHATELY 

2

Hannah Berry 
South Yorkshire (West) Coroner’s Court 
Medico-Legal Centre 
Watery Street 
Sheffield  
S3 7ES  

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

24 June 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Sophie Hindmarsh who 
died on 17 August 2022.   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 April 
2024 concerning the death of Sophie Hindmarsh on 17 August 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Sophie’s family and loved ones. NHS England are keen to assure 
the family and the coroner that the concerns raised about Sophie’s care have been 
listened to and reflected upon.   

Your Report raised the concern over significant delay in offloading patients at hospitals 
which  tied  up  ambulance  resource  and  impacted  the  ambulance  service’s  ability  to 
respond to emergency calls.  

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, 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 improving flow through hospitals 
and reducing handover delays, speeding up discharges from hospitals, expanding 
new services in the community, all of which should help ambulance crews to get 
back on the road to the next waiting patient more rapidly. 

Whilst ambulance response times have not returned to pre-pandemic levels, 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, 
with ambulance services 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 present 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. 

NHS  England  has  also  engaged  with  West  Yorkshire  Integrated  Care  Board  (ICB), 
who we note will also be responding to your Report and we have been asked to be 
sighted on their final response to you. NHS England are advised that there has been 
an improved trajectory of ambulance handovers within South Yorkshire since 2022, 
and that measures to drive improvements include:  

Investment in crews, fleet and the Emergency Operation Centre (EOC) 

•  Joint escalation processes within South Yorkshire  
• 
•  EOC  clinical  workforce  enhancements  to  support  both  calls  and  crews 
attending in the community, to promote appropriate alternative care pathways. 

In  June  2023,  NHS  England  published  the  NHS  Long  Term  Workforce  Plan,  which 
sets out how we will grow, train, retain and reform the NHS workforce over the next 
fifteen years to help meet the growing demands on our services. It is underpinned by 
the  biggest  recruitment  drive  in  NHS  history  and  includes  an  expansion  of  medical 
specialty training for urgent and acute care.  

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

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

Twitter: @WYpartnership   

24 June 2024 

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

Dear Ms Berry, 

Thank you for your letter of 29 April 2024 in relation to the Regulation 28 report to 
prevent future deaths, following the inquest into the death of Sophie Hindmarsh. 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 condolences to the family of Sophie on behalf of the 
Yorkshire Ambulance Service, NHS West Yorkshire Integrated Care Board as the 
lead commissioner, and our partners across the region. I am sorry for their loss and 
the circumstances surrounding the death of Sophie.  

I hope this letter provides reassurance of our joint commitment to delivering services 
that meet the needs of the population within Yorkshire and the Humber, and that the 
actions we have taken reflect the lessons learnt and the investment and changes 
made.  

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

•  The ambulance service was called at 0245 on 21 July 2022 and the call was 
coded as a Category 2 at 0251 call requiring a response within 40 minutes. 
The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 
minutes after the call. 

 
               
 
 
 
 
 
 
 
 
 •  There was a significant delay in handing over patients at hospitals which 

meant they were unable to respond to emergency calls. 

Background 

During the financial year 2022/23 the ambulance services in the country were 
experiencing increased pressure, ultimately resulting in extended response times 
that did not meet national standards. During this period the average response time 
for Category 2 calls nationally (based on the mean) extended to 50 minutes and 0 
seconds, with the July 2022 position being worse at 58 minutes 53 seconds.  

The overall systemic pressure felt across the country impacted YAS, which had 
average Category 2 response times of 42 minutes and 4 seconds across the year 
and 44 minutes and 44 seconds in July 2022. Significant numbers of patients waited 
much longer than these average response times, as was the case with Sophie. I am 
sorry we were unable to provide a better service to Sophie and others at this time. 

YAS operates within a broader system. Pressure was also experienced within this 
wider healthcare system, with associated difficulties in the timely discharge of 
patients to the most appropriate care settings, consequently reduced patient flow 
through acute hospitals, ultimately leading to extended handover delays with 
Emergency Departments. 

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 across 
the country. 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 is 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 timelier response and 
meet increasing demand.   

Within the Yorkshire and Humber region there have been improvements in response 
times subsequently with the average Category 2 times of 32 minutes and 26 
seconds in 2023/24. In April 2024, YAS average Category 2 response times reduced 

 
 
 
 
 to 26 minutes and 3 seconds and in May 2024 the figure was 31 minutes and 21 
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. 

During the calendar month July 2022, the mean ‘handover’ time within South 
Yorkshire was 37 minutes and 32 seconds. The most recent calendar month of 
reporting (May 2024) showed that the mean ‘handover’ times within South Yorkshire 
were 29 minutes and 47 seconds. Further work continues to support other 
improvements. In collaboration with the acute trusts, YAS has implemented Quality 
Improvement initiatives to improve handovers. This helps further reduce the amount 
of ‘lost ambulance handover time’ and allow ambulances to return to the respond to 
emergency calls in a more timely manner.    

As part of operational planning for 2024/25, South Yorkshire ICB 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, operational 
management and leadership to support this improvement.  

Further support measures  

YAS and Sheffield Teaching Hospitals (including other South Yorkshire Hospitals) 
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. 

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 and timely release of an ambulance 
crew to attend to a specific 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 meet people’s needs and avoid 
hospital attendance where appropriate. This 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 meet people’s 
needs and improve hospital flow and ambulance turnaround. 

The EOC have continued to invest in the clinical workforce using 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 their referral processes to other services therefore 
appropriately diverting demand into alternative care pathways. A System 
Coordination Centre (SCC) has also been developed over the past year. The SCC 
exists to be 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 

This Regulation 28 has been discussed at the YAS Clinical Quality Oversight Group 
with senior clinical leaders of the constituent organisations to share the matters of 
concern raised across the Yorkshire and Humber region. This reports to the ELB 
which has oversight of the Ambulance Service in Yorkshire. Within South Yorkshire, 
this Regulation 28 report and matters of concern will be shared through the Urgent 
and Emergency Care Alliance Board made up of senior leaders from all of the 
constituent bodies.  

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 you can see that we 
are making progress on response times and striving to reduce handover times.  

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