Susan Dear

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

15th November 2024 

Our ref: 

HM Coroner Hannah Godfrey 
Berkshire Coroners Court, 
Reading Town Hall, 
Blagrave Street, 
RG1 1QH 

By email:

Dear Ms Godfrey,  

Thank you for the Regulation 28 report of 20 September 2024, sent to the Secretary of State 
about  the  death  of  Mrs  Susan  Dear.  I  am  replying  as  the  Minister  with  responsibility  for 
urgent and emergency care.       

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Dear’s 
death and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. 

The  report  raises  concerns  over  service  pressures  at  South  Central  Ambulance  Service 
NHS  Trust  (SCAS)  and  ambulance  handover  delays  at  Royal  Berkshire  Hospital  and 
Wexham Park Hospital.  

In preparing this response, my officials have made enquiries with NHS England to ensure 
we  adequately  address  your  concerns.  I  understand  NHS  England  are  writing  to  you 
regarding  regional  service  improvements  and  actions  being  taken  by  SCAS.  I  am  also 
informed  they  will  respond  to  your  concerns  on  appropriate  public  education  about  the 
circumstances in which it is appropriate to call 999. 

At a national level, this government is committed to returning to the safe operational waiting 
time  standards  set  out  in  the  NHS  Constitution.  In  doing  so  we  will  be  honest  about  the 
challenges facing the health service and serious about tackling them. The Health Secretary 
ordered an independent investigation of NHS performance to provide an assessment of the 
issues  and  challenges  it  faces.  This  reported  on  12th  September  2024  and  the 
investigation’s findings will feed into the government’s work on a 10-year plan to radically 
reform the NHS and build a health service that is fit for the future.  

In the short-term, a range of action is being taken by the NHS this year to improve urgent 
and emergency care performance, including by maintaining capacity gains in acute hospital 
beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
  
  
 
  
 acute  and  non-acute  services  across  bedded  and  non-bedded  capacity,  and  directing 
patients to more appropriate services in the community where these can better meet their 
needs.   

Turning  to  your  concerns  on  ambulance  handover  delays,  this  government  is  working  to 
improve hospital flow to make sure people do not spend longer than necessary in hospital 
and  reduce  delayed  discharges.  We  will  tackle  delayed  discharges  by  developing  local 
partnership working between the NHS and social care  – and making sure people get the 
right support from health and social care services to return home as soon as possible.  

We have also ensured that every acute hospital has access to a care transfer hub. These 
hubs bring together professionals from the NHS and social care to manage discharges for 
people with more complex needs who need extra support.  In the integrated care systems 
that face the most discharge delays, the Department is working directly with partners across 
health and social care to drive improvements.   

Health  and  care  systems  and  providers  should  work  together  to  ensure  that  efforts  to 
discharge  individuals  from  hospital  into  social  care  are  joined  up  and  make  best  use  of 
available resources, in line with the duty to cooperate set out in Section 82 of the NHS Act 
2006. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Ms Hannah Godfrey 
Area Coroner 
Berkshire Coroner’s Office  
Reading Town Hall  
Blagrave Street  
Reading  
RG1 1QH 

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

11 November 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Susan Dear who died on 
4 January 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  20 
September 2024 concerning the death of Susan Dear on 4 January 2023. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to  Susan’s family and loved ones. NHS England are keen to 
assure the family and the Coroner that the concerns raised about Susan’s care have 
been listened to and reflected upon.   

Your Report raises concerns over the level of demand on South Central Ambulance 
Service  (SCAS),  and  notes  that  there  was  a  continuing  risk  that  demand  for 
emergency  ambulances  would  outstrip  resources.  Your  Report  also  raises  that  a 
substantial  root  cause  of  the  problem  was  handover  delays  at  the  Royal  Berkshire 
Hospital and the Wexham Park Hospital.  

NHS  England  recognises  the  significant  pressures  on  all  NHS  services,  including 
ambulances, and continues to prioritise improvements to Category 2 response times, 
as  well  as  4  hour  performance  in  Emergency  Departments  (EDs)  to  recover  and 
improve urgent and emergency care (UEC) services. Despite significant challenges, 
including unprecedented industrial action and higher than anticipated demand, there 
has  been  a  marked  improvement  in  2023/24,  with  over  2.5  million  more  people 
completing their A&E treatment within 4 hours compared to 2022/23. 

Work has also focused on the need to increase ambulance capacity through growing 
the  workforce,  improving  flow  through  hospitals  and  reducing  handover  delays, 
speeding up discharges from hospital and expanding 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  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 continue their recovery after discharge 
•  urgent community response teams provided 720,000 people with an alternative 

to going to hospital between April and January.  

•  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. 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  

the  NHS  standard  contract states 

Within  Emergency  Departments, 
that  all 
handovers of patients  between  ambulances  and  A&E  must  take  place  within  15 
minutes,  with  none  taking  more  than  30  minutes.  The  clock  begins  when  an 
ambulance  arrives outside  an  A&E department and  stops  when a  clinical  handover 
has been fully completed to A&E staff. Key Lines of Enquiry (KLOEs) have previously 
been developed by NHS England to support ambulance and acute providers to identify 
key opportunities to reduce ambulance handover delays and improve patient flow, as 
outlined in the UEC Recovery Plan (2023). 

Ambulance handover times vary across England and, at a local level, acute hospital 
providers are  working with  ambulance  providers to accept  patient  care  transfers as 
soon as the patient enters the hospital site, with some acute hospital providers having 
designated  clinical  teams  to  accept  ambulance  handover  patients,  with  escalation 
plans in place when demand increases beyond current capacity levels. This continues 
to  be  a  focus  for  recovery  at  a  national  level  for  year  two  of  NHS  England’s  UEC 
Recovery Plan.   

My regional colleagues in the South East have engaged with SCAS on the concerns 
raised  in  your  Report.  There  are  number  of  local  initiatives  and  improvement 
programmes  underway  to  improve  their  performance  and  ensure  that  the  Trust  is 
delivering the best care to its patients. They advise that they are on target to employ 
an  additional  100  paramedics  this  year,  through  an  international  recruitment 
programme, and that they have purchased additional ambulances through the national 
procurement framework. They recently received the first batch of 53 new ambulances 
and are expecting delivery of a further 71 next month. They are also working hard to 
increase efficiencies across the service, and have been working closely with all of their 
providers to  identify  suitable  care  pathways  that  avoid patients  being  unnecessarily 
conveyed to EDs and ensure quicker admittance to the correct specialty. 

My  regional  colleagues  are  also  in  the  process  of  engaging  with  Buckinghamshire, 
Oxfordshire and Berkshire West Integrated Care Board (BOB ICB) and Frimley ICB, 

 the  responsible  commissioners  for  Royal  Berkshire  Hospital  and  Wexham  Park 
Hospital ED services, regarding your concerns about ongoing handover delays. We 
would expect the Department of Health and Social Care’s response to the Coroner to 
respond to your concerns over the national social care system.  

Your Report also raised the concern that  UEC resources were being wasted due to 
the ignorance of some members of the public,  and that this was unlikely to improve 
without a programme of public education regarding when it is appropriate to call 999.  

There are national efforts underway to educate the public on when it is appropriate to 
call  999.  NHS  England  runs  a  series  of  national  public  education  campaigns 
signposting to the range of different services available. These also include resources 
around symptoms such as those which indicate a possible stroke or heart attack and 
require emergency treatment, as well as how and when to use NHS 111, a GP and 
pharmacist.  

Systems and providers are also encouraged to use the variety of campaign resources 
available to run their own local campaigns such as Stay Well this Winter, focusing on 
prevention and encouraging the uptake of Covid-19, flu and RSV vaccinations.  

SCAS  advise  us  that  they  regularly  publish  articles  on  social  and  other  platforms 
during  periods  of  high  demand,  directing  the  public  to  contact  other  health  care 
services  such  as  111  or  their  local  pharmacy  for  conditions  that  can  be  managed 
through that service. 

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 
Susan, 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