Susan Shipley

Ms C Cundy 
HM Area Coroner, North Yorkshire and York 
The Old Courthouse 
3 Racecourse Lane 
Northallerton 
North Yorkshire 
DL7 8QZ 

Springhill 2 
 Brindley Way 
Wakefield 41 Business Park 
Wakefield  
WF2 0XQ  

Tel: 0845 124 1241 

Email: 

23 December 2024 

By email only: 

Dear Ma’am, 

Re: Inquest touching the death of Susan Shipley 

I write on behalf of Yorkshire Ambulance Service NHS Trust (YAS) and in response to the 
Regulation 28 report on this matter, issued on 28 October 2024. 

I am aware of the circumstances of Mrs Shipley’s sad death, and I offer my sincere 
condolences to her family. I also take this opportunity to say how sorry I am that Mrs 
Shipley sustained a fall whilst in our care, and that injuries sustained from the fall 
contributed to her deterioration.  

I have been appraised of the findings of your inquest, in particular that an initial ‘fit to sit’ 
decision was incorrect and led to inappropriate use of a hospital wheelchair when 
transferring Mrs Shipley. This is reflected in your matters of concern, which are:  

“a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was 

undertaken involving the parties mentioned above;  

b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to 

weight bear;  

c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second 

ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to 
sit, and the role of the HALO in this assumption;  

d) The absence of evidence that all relevant learning arising from the above has occurred 
and any actions arising from such learning have been completed, particularly in relation to 
the first paramedic crew and the HALO;  

www.yas.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 e) The potential risk of death to others in the event of a recurrence of any of the above.” 

To address these concerns, I have taken advice from YAS’s Executive Medical Director, 
who informs me as follows:  

The current ‘fit to sit’ process 

“‘Fit to Sit’ is an initiative used in the NHS to assess patients in emergency departments or 
urgent care settings. If satisfied it means that a patient is considered stable enough to wait 
for treatment without the need for a hospital bed or stretcher and can instead remain 
seated in a chair or other comfortable seating. This approach aims to streamline the flow of 
patients and prioritises the use of beds for those who truly need them. The approach 
promotes greater independence as sitting in a chair can feel more natural and empowering 
to patients, as they retain more mobility, can engage with staff or family members more 
comfortably, and generally feel less like they are “confined” to a bed. 

YAS does not have a specific ‘fit to sit’ policy, instead it uses the self-handover process, 
the flowchart for which I attach as Appendix 1. This has inclusion and exclusion criteria 
outlining which patients are appropriate for this process. It includes a National Early 
Warning Score 2 of above 3 as a potential exclusion. 

This process feeds into York and Scarborough Teaching Hospitals ‘fit to sit criteria’, 
attached as Appendix 2. Patients who are assessed as meeting the YAS self-handover 
criteria are deemed as fit to sit in the hospital flowchart. Patients who do not meet the YAS 
self-handover criteria are assessed by a receiving clinician at the Emergency Department, 
be that a nurse, doctor, or Advanced Clinical practitioner, and then re-assessed for 
suitability in this regard.  

Decisions on ‘fit to sit’ 

The decision to classify a patient as "fit to sit" is ultimately based on the clinical judgment 
of healthcare professionals.  Their experience and expertise are essential in assessing 
each patient’s individual condition, stability, and care needs. Clinical judgment allows them 

to decide whether a patient can be safely monitored while seated or requires a bed. 
Experienced healthcare professionals can detect subtle signs that might indicate 
underlying instability or time critical presentations, even if initial vital signs appear normal.  

Assessment in this regard should not end with the paramedic’s initial assessment. The 
patient should be continuously reassessed throughout the handover process and beyond 
by the receiving department for their suitability as to remain a ‘fit to sit’ patient and 
monitored for any signs of change in their condition. This proactive monitoring helps 
ensure that patients receive appropriate care if their status shifts unexpectedly. Clinical 
staff must weigh the availability of beds and resources against patient safety, ensuring that 
the most critical patients receive immediate care.  

While guidelines and protocols help inform "fit to sit" decisions, clinical judgment lies at the 
core of this approach. Paramedics are degree educated, registered healthcare 
professionals who apply their experience, knowledge, and intuition to make decisions that 

 maximise patient safety and ensure efficient use of resources in high-demand settings. 
Similarly, the wider clinical workforce outside of paramedics should be supported by the 
receiving departments in this regard.  

Actions in response to Regulation 28 report 

YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and 
‘self-handover’ being used interchangeably between organisation when in fact these are 
not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to 

support clinicians in this decision making that links to the existing self-handover process.  It 
will go through internal review at YAS’s Clinical Quality Development Forum before being 
finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to 
amendments dependent on feedback from these groups hence it not being included within 
this letter. Once formally agreed it will be disseminated across the organisation for use by 
all clinical staff.  

This policy will emphasise the need for documenting the reasoning behind the clinical 
decision on the electronic Patient Record, ensuring it is visible to subsequent clinicians 
assessing the patient.  It will also mandate that the ‘fit to sit’ decision needs to be reviewed, 
and the patient be reassessed by all subsequently attending ambulance staff taking 
responsibility for the patient. The standards of documentation within ambulance patient 
care records remain a continued area of focus at regional investment days, with oversight 
from the regional advanced paramedic clinical leads.  

Additional actions 

This very sad event contributed to the launch of a collaborative clinical safety group 
attended by operational and clinical leads from the ambulance service and York and 
Scarborough Hospitals. This meeting reviews cases such as this with the aim to avoid 
future patient harm caused by handover delays and ambulance queues. Mrs Shipley’s care 
has been discussed within this forum and an action taken to encourage ambulance crews 
to seek to override a divert when presented with a patient requiring a specialist service 
available at the hospital that is on divert.    

Additionally, a case-based discussion has been held with the attending clinicians at the 
first ambulance call which led to the patient being transported to Scarborough Hospital. 
This was led by our Advanced Paramedic Clinical Lead and involved critically reflecting to 
enable points for consideration from a safety perspective to be highlighted. There is 
planned feedback for the HALO.  

The second ambulance crew responsible with transporting the patient from Scarbrough to 
York participated in an After-Action Review, attended by system partners and key 
stakeholders. This again enabled critical reflection of the events and identified systemwide 
learning. As a result of this discussion, a notice has been issued to all patient facing 
ambulance teams in Humber and North Yorkshire by the area’s Consultant Paramedic 

regarding the correct use of portering chairs and the need for continued dynamic risk 
assessment when transporting patients between ambulances and the receiving 

 departments. I understand that the work that is being undertaken by YAS Health and 
Safety team on use of appropriate patient transport aids was outlined at the inquest. 

Following the conclusion of your inquest, the complexities and potential for learning was 
discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive 
Medical Director. From this he commissioned a full investigation into the care of Mrs 
Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” 
has been initiated, which focuses on identifying learning responses to improve our service 
to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to 
participate in this investigation.  

Investigations of this nature can take some time to complete as there is a breadth of 
information to process, as a number of other patient experiences will be reviewed and 
evaluated so appropriate learning can be identified to inform change for the future and 
better improve our practices. The timescale for the completion of this investigation and 
preparation of the report will be February/March 2025.   

Although not yet completed, the investigation is well under way, and I can share the 
following. YAS had identified that Moving and Handling was a local priority theme upon 
introduction of the Patient Safety Incident Response Framework (PSIRF). A dedicated 
Moving and Handling focus group meets regularly to discuss incidents involving this 
theme. This group is facilitated by our Health and Safety Manager, supported by our 
Moving and Handling Lead and Patient Transport Service Quality Lead.  

This group ensures a collaborative and clear focus on providing the guidance and support 
to staff in providing safe care to patients. One of the main areas of focus is the transfer of 
patients to hospital care, specifically the use of the hospital portering wheelchairs.  

In October 2024, following a number of pieces of research work by our Moving and 
Handling Lead, a hospital portering wheelchair equipment risk assessment was introduced 
which identified tasks at the highest risk, namely transporting patients from vehicle to 
hospital over uneven ground without use of a lap belt, and using a wheelchair for access or 
egress to/from ramp access ambulance vehicles. Early indications highlight that the 
introduction of the risk assessment has helped identify specific actions that are required to 
reduce the risks. This work remains ongoing which will allow us to draw conclusions on its 
effectiveness in terms of reduction of number of patient safety incidents specific to moving 
and handling.  

In addition, the investigation will review the entire timeline and therefore also include the 
nature of the initial call, the management and impact of the divert, points for ‘fit to sit’ 
decisions, the role of the HALO, and transport to the specialist hospital.  

A detailed, comprehensive Patient Safety Investigation incident report will be produced and 
will be made available to the family and relevant stakeholders to view. 

 
 I was so sorry to hear of the death of Mrs Shipley in these circumstances. I do hope this 
letter provides you and her family with some assurance that we have put in place, and 
continue to explore, measures to ensure greater safety for our patients.  

My thoughts remain with Mrs Shipley’s family. 

Yours sincerely 

Chief Executive 

 
 
 
 
 
 Appendix 1 

 
 
 
 
 Appendix 2