Josh Smith

Ms Jessica Swift 
Assistant Coroner 
East Riding and Hull Coroner’s Service 
The Guildhall 
Aldred Gelder Street 
Hull  
HU1 2AA 

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

25/09/2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Josh Andrew Smith who 
died on 22 December 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 July 
2024 concerning the death of Josh Andrew Smith on 22 December 2022. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Josh’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the  Coroner that the concerns raised about  Josh’s care have 
been listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Josh’s  family  or  friends.  I  realise  that 
responses to Coroner’s Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your  Report  raised  concerns  over  continued  delays  to  ambulance  handovers  at 
hospitals and the impact this was having on the speed of ambulance response times.  

NHS  England  recognises  the  ongoing  significant  pressure  on  all  NHS  services, 
including ambulances, and continues to prioritise improvements to response times, as 
well  as  4-hour  performance  in  Emergency  Departments,  to  recover  and  improve 
urgent  and  emergency  care  services.  Despite  significant  challenges,  including 
unprecedented industrial action and higher than anticipated demand, there has been 
a  marked  improvement,  with  over  2.5  million  more  people  completing  their  A&E 
treatment within 4 hours in 2023/24 compared to 2022/23. 

National work has also focused on the need to increase ambulance capacity through 
growing the workforce, improve flow through hospitals and reduce handover delays, 
speed up discharges from hospital and expand new services in the community; all of 
which support improved patient flow. The NHS is also working more closely with local 
authorities to improve the timely discharge of patients and has developed discharge 
metrics to monitor performance improvements. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 Response times for Category 2 ambulance calls have improved over the  past year, 
with an average response time over 13 minutes faster compared to the previous year. 
Other benefits for patients include:  

•  Tens of thousands more people received the care they needed to return home 
quickly and safely due to the expansion of same day emergency care (SDEC) 
services.  

•  On average, around 500 fewer patients a day had to spend the night in hospital 
because of a discharge delay, and 13% more patients received a short-term 
package  of  health  or  social  care  to  help  them  continue  their  recovery  after 
discharge. 

•  Urgent community response teams provided 720,000 people with an alternative 

to going to hospital between April and January 2024.  

•  Virtual  wards  have  supported  more  than  240,000  people  to  get  the  hospital-
level care and monitoring they needed in the comfort of their own home.  

The  ambitions  for  2024/25  have  recently  been  set  out  in  the  NHS  priorities  and 
operational planning guidance. Relevant to your Report, these are:  

• 

• 

Improve A&E performance with 78% of patients being admitted, transferred, or 
discharged within 4 hours by March 2025.  
Improve  Category  2  ambulance  response  times  relative  to  2023/24,  to  an 
average of 30 minutes across 2024/25.  

NHS England’s operational planning guidance has asked systems to focus on three 
areas to deliver these ambitions:  

1.  Maintaining the capacity expansion delivered through 2023/24.  
2.  Increasing the productivity of acute and non-acute services across bedded and 
non-bedded capacity, improving flow and length of stay, and clinical outcomes. 
3.  Continuing to develop services that shift activity from acute hospital settings to 
settings  outside  an  acute  hospital  for  patients  with  unplanned  urgent  needs, 
supporting proactive care, admissions avoidance and hospital discharge. 

During 2024/25, providers have access to funding of £150 million to support specific 
local improvement plans for urgent services, including for mental health care. These 
new improvements will support patients being treated more quickly in A&E or by other 
services in the community. Up to £150 million will also be available to incentivise the 
best performing areas and those that improve fastest. The NHS and local authorities 
will  also  work  together  to  expand  intermediate  care  services,  both  in  people’s  own 
homes and in community beds, thanks to the additional £400 million Better Care Fund 
(BCF) available to support further improvements in hospital discharge. There will also 
be  further  improvements  to,  and  co-ordination  of,  community-based  services  that 
support  people  to  avoid  ambulance  call-outs  and  hospital  admissions,  by  treating 
people in the most appropriate place for their level of need. 

NHS England will also be prioritising: 

• 

Improving  the  length  of  stay  for all  admitted patients  (specifically emergency 
admissions with a length of stay of 1+ day). 

 
 
 
 
 
 
 
 
 •  Reducing delays. 
• 

Improving the length of stay in NHS commissioned community beds. 

My  regional  colleagues  in  the  North  East  &  Yorkshire  have  also  engaged  with 
colleagues at the West Yorkshire Integrated Care Board (WYICB) in relation to your 
concerns, who have advised us of several measures underway to improve flow and 
ambulance delivery. I understand that WYICB are responding directly to the Coroner, 
and I refer you to their response for further information on local and system steps.  

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Josh, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

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

Twitter: @WYpartnership   

9 September 2024 

Jessica Swift 
H.M Assistant Coroner for the City of Kingston Upon Hull and East Riding of 
Yorkshire 
Via email: 

Dear Ms Swift, 

Thank you for your letter of 15 July 2024 in relation to the Regulation 28 report to 
prevent future deaths, following the inquest into the death of Josh Andrew Smith. 
This was issued to:  

1. NHS England, Wellington House, 135-155 Waterloo Road, London, SE1 8UG 

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

I would like to begin by offering condolences to the family of Josh on behalf of the 
Yorkshire Ambulance Service (YAS), NHS West Yorkshire Integrated Care Board 
(WYICB) as the lead commissioner, and our partners across the region. I am sorry 
for their loss and the circumstances surrounding the death of Josh.  

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 have asked for a response from WYICB as the lead commissioner of services 
from 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: 

•  Delays in community ambulance responses had improved but continue to 

remain outside of the target response standards (both on average and at the 
90th centile).  

•  The national target for hospital handover by the ambulance service, of 15 
minutes, is still not being achieved. Whilst there has and continues to be 
efforts made by the ambulance service and acute hospitals to decrease 

 
               
 
 
 
 
 
 
 
 delays, extended handovers continue to impact upon the speed of the 
ambulance response to patients waiting within the community. 

Background 

The winter of 2022/23 was a period of extreme pressure across the NHS. Pressure 
was also evident in the wider healthcare system in Yorkshire and the Humber, with 
associated difficulties in the timely discharge of patients to the most appropriate care 
settings. This was due to a number of factors that combined to make a significant 
impact. 

During this time, patients and families faced delays in assessment and treatment, 
and patient flow through acute hospitals was significantly impacted. There were 
some hospitals that experienced ambulances queuing outside of their Emergency 
Departments (EDs) due to overcrowding and a lack of beds to move patients to. The 
pressure was further exacerbated by very high levels of Covid and Influenza 
infections, coming at the same time as a national spike in Streptococcal infections in 
children. These widespread infections impacted on all parts of the population, 
including our staff, and this resulted in high levels of sickness absence throughout all 
areas of the NHS. As a result, overall ambulance mean response times (December 
2022, Category 1) increased to 12 minutes and 58 seconds in the Yorkshire and 
Humber region, and 10 minutes and 40 seconds in Hull.  

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 EDs: 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 to improve performance and to 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.  

 
 
 
 
 
 The national target focuses on Category 2 responses, but the overall actions are 
intended to positively impact on all response category times within Yorkshire and 
Humber.  

I am pleased to inform you that because of some of the actions taken within the 
Yorkshire and Humber region we have seen improvements in response times. In 
August 2024 the mean Category 2 response time against the national target was 30 
minutes and 42 seconds; in Hull the mean Category 2 response time was 27 minutes 
and 10 seconds, and this reduced to 6 minutes 21 seconds for Category 1. The latter 
is within the national standards. 

Hospital Handovers and Ambulance Turnaround Times 

The correlation between handover delays at Emergency Department and overall 
ambulance response times is widely acknowledged. Handover times vary amongst 
our acute trusts in the region, and we seek to ensure the root causes are understood 
and remedial action is undertaken to improve individual organisations performance. 

During the calendar month December 2022, the mean ‘handover’ times at Hull Royal 
Infirmary (HRI) increased to 1 hour, 27 minutes and 50 seconds. The most recent 
calendar month of reporting (August 2024) showed that the mean ‘handover’ times at 
HRI had reduced to 33 minutes and 45 seconds. Despite recent improvements, HRI 
continues to have longer handover times when compared to many other trusts in the 
Yorkshire and Humber Region, this continues to be a local, system and regional 
priority with scrutiny and support at all levels to ensure delivery on Trust targets.  

As part of operational planning for 2024/25, Humber and North Yorkshire ICB has set 
out an improvement trajectory for HRI to reduce hospital handover times by 3 
minutes against 2023/24 baseline with a cap at 50 minutes hospital handover times.  

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 timelier 
manner.    

In addition, as part of winter planning for 2024/25, NHS England North East and 
Yorkshire Region are working with each ICB, acute Trusts and YAS to have a 
specific focus on improving hospital handover times through rapid improvement 
initiatives. This work will focus on specific plans for each acute Trust with a drive to 
achieve a national ambition of zero tolerance above 45 minutes. 

Additional action being taken to improve ambulance response times 

Implementation of Duty to Rescue protocol – this new clinically led protocol was 
introduced ahead of the winter period (2023/24) and is now enacted at times of 
significant operational pressure and has been utilised in Hull. On occasions when 
there are high number of ambulances in an acute provider 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 waiting to be conveyed to hospital 
and is deteriorating. The introduction of this protocol has been welcomed by all 
parties and allows for better management of clinical risk in the system.  

Alternatives to EDs – 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 EDs for suitable patients and therefore meet people’s 
needs and improve hospital flow and ambulance turnaround, additional 
appointments are being made available across Hull and East Riding Practices.  

An Urgent Treatment Centre (UTC) has been implemented at HRI to stream 
patients who present with urgent needs and reduce flow into the ED. There is an 
established ambulance ‘fit to sit’ pathway to avoid ambulance crews having to wait 
and handover. An Acute Respiratory Hub in place in the East Riding – to support 
patients with acute respiratory conditions and avoid conveyance to hospital. 
Established cohorting process in place between YAS and Hull University Teaching 
Hospitals Trust (HUTH) to release crews back into the community. A programme of 
work in place to improve flow in HRI, and discharge to support flow from ED to 
wards.  Improvements have already been made to the numbers of patients who have 
“no criteria to reside”. 

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 coordination 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 Yorkshire and Humber YAS Clinical 
Quality Oversight Group. This is a group of senior clinical leaders of the constituent 

 
 
 organisations sharing matters of concern raised across the Yorkshire and Humber 
region. This reports to the ELB, noted earlier which has oversight of the Ambulance 
Service in Yorkshire and includes representatives from YAS and all of the Integrated 
Care Boards. I chair that Board.  

This response and the Regulation 28 report and matters of concern will be shared 
with Hull and East Riding Urgent and Emergency Care Transformation Programme. 
This oversees the local improvement of ambulance handover and delivery of timely 
responses in that community.  

These governance arrangements exist to oversee delivery and operational weekly 
executive meetings have been established for additional assurance. 

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 detail of the 
actions we have taken and the ongoing focus on this agenda provides you with 
assurance that we are working collectively to improve patient safety, and that we 
continue to make progress to improve response times and to reduce hospital 
handover times.  

Finally, I would like to also assure you of our joint commitment to delivering safe 
services that meet the needs of the population within Yorkshire and the Humber, and 
that the actions we have taken reflect the lessons learned in this case. 

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