Colin Wiles

County Hall   Beverley   East Riding of Yorkshire   HU17 9BA   Telephone (01482) 393939
www.eastriding.gov.uk

   Director of Locality Wellbeing and Safeguarding

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

FOLLOWING THE INQUEST TOUCHING THE DEATH OF COLIN WILES

PROVIDED BY 

 – HEAD OF SERVICE, SAFEGUARDING AND QUALITY

ASSURANCE, ADULT SOCIAL CARE AND HEALTH, EAST RIDING OF YORKSHIRE
COUNCIL

There are four MATTERS OF CONCERN to note in this regulation 28 report. The local authority
can respond only to MATTER OF CONCERN (1) as follows:

No Vulnerable Adult Risk Management meeting was held despite multifactorial
concerns with Mr Wiles’ comorbities and self neglect leading to poor living conditions
and increased risk to his safety

The evidence submitted to the inquest demonstrates how a Vulnerable Adult Risk Management
(VARM) meeting was considered by the social worker in this case but did not happen. Whilst Mr
Wiles was resisting formal care interventions and was believed to have the mental capacity to make
that decision, he was continuing to engage with professionals and accept some, if not limited help,
which was a protective factor. A VARM would more often be requested for those people who are at
risk but refusing all contact with services, although a VARM could have been used in this case to
assure all professionals that they were doing all they could to support and safeguard Mr Wiles and
give Mr Wiles the opportunity to comment on whether there was anything else he thought they
could do to support him.

The local authority adult social care and health service (ASCH) and the east riding safeguarding
adults board (ERSAB) recognise that the use of VARM should be a key consideration and mechanism
in the practice system to ensure it is utilised for all people for whom it would be of benefit. There is
an opportunity for the system to utilise the VARM process more regularly when supporting people
in circumstances like Mr Wiles to ensure that professionals are working together with and for the
person concerned and accept that this is an area for continuous improvement.

The current VARM procedure is available to all professionals and people in the east riding on the
ERSAB website and guides them through the processes and paperwork involved (included as
appendix 1). Training is provided to practitioners across the health and care system in the east riding
on the use of VARM both through the ERSAB and the local authorities internal learning and skills
team. To enable development in this area, the ERSAB and ASCH have collaborated with Hull City
Council’s safeguarding adults board and Adult Services to review and renew the VARM procedure to
contemporise the approach and develop a more seamless and accessible procedure in this
geographical area. The VARM training is therefore currently under review and will be relaunched
following the completion of this work to ensure and enable an effective roll out of the new
procedure which will be called Multi Agency Risk Management (MARM) meeting procedure. This is
expected to be finalised in early 2025. VARM training is not currently a mandatory requirement for
staff in ASCH staff however, MARM training being mandatory for practitioners going forward will be
considered by the service at our practice development board which is chaired by our Head of
Service for Safeguarding and Quality Assurance.

Interim Executive Director of Adult Social Care and Health (DASS)

Ms Sally Robinson 
HM Assistant Coroner  
East Riding of Yorkshire and  
City of Kingston Upon Hull 
The Guildhall 
Alfred Gelder Street  
Hull  
HU1 2AA 

Dear Coroner, 

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

22 January 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Colin Wiles who died on 
27 March 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  24 
November 2024 concerning the death of Colin Wiles on 27 March 2023. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Colin’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the Coroner that the concerns raised about Colin’s care have 
been listened to and reflected upon.   

My response to the Coroner focuses on those areas of concern that sit within NHS 
England’s  national  policy  and  programme  remit.  It  is  appropriate  for  the  other 
organisations you have addressed your Report to, Hull University Teaching Hospitals 
NHS  Trust  and  East  Riding  of  Yorkshire  Council  Adult  Social  Care  and  Health,  to 
address the local and system concerns you raise.  

You raised the concern that it does not seem clear whether callers are advised to call 
the emergency services back if they continue to have concerns. 

Instructions on worsening conditions, including specifically to call back on 999 should 
the patient’s  condition  change  or  deteriorate,  are  standard  components  of  the  case 
exit script. If the call is made via a second party, ambulance services should ensure 
there is a process in place to be assured the caller is able to monitor the condition of 
the patient, and that they can be called back when the patient is not able to call back 
or answer a call themselves. If this was not provided in a clear and easy to interpret 
manner,  this  is  a  matter  for  the  relevant  ambulance  service  to  resolve  locally  as  a 
training issue for their call handlers. 

You also raised a concern over the waiting times for ambulances to handover patients 
at Hull Royal Infirmary, which were excessive on 27 March 2023, leading to 160 hours 
of lost ambulance time. 

Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers 
are  essential to ensure  patients  reach  definitive  care promptly,  which  includes  both 
those waiting to receive care in the emergency department (ED), and those waiting in 

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
  
  
 
 
 the  community.  NHS  England  are  continuing  to  work  with  trusts  and  services  with 
significant  handover  challenges  at  the  ‘front  end’,  alongside  recognising  the 
importance  of  reducing  length  of  stay  and  timely  discharge  to  maintain  adequate 
patient flow and allow new patients to be handed over more promptly to EDs. 

To deliver this, the NHS’s ambitions for 2024/25 have 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 

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. 

Evidence of the impact of system actions to improve patient flow and relieve pressures 
on EDs includes: 

• 

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 

Additionally,  during  2024/25,  providers  have  access  to  £150  million  of  funding  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  length  of  stay  for  all  admitted  patients  (specifically  emergency 
admissions with a length of stay of 1+ day) 
reducing delays 
improving length of stay in NHS commissioned community beds 

My regional colleagues for  North East and Yorkshire have also engaged with Humber 
Health  Partnership,  of  which  Hull  University  Teaching  Hospitals  NHS  Trust  is  a 
member,  regarding  the  concerns  raised  in  your  Report.  We  note  and  welcome  the 
actions they are taking to reduce ambulance handover times and restore patient flow. 
We are advised that the Trust has also implemented a Temporary Escalation Space 
(TES)  and  Boarding  Standard  Operating  Procedure  to  improve  patient  flow  and 
increase availability of beds for patients attending the Emergency Department. I refer 
you to Humber Health Partnership’s response to your Report for further information.   

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 Colin, 
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

3 February 2025 

Ms Sally Robinson 
Assistant Coroner 
The Guildhall 
Alfred Gelder Street 
Kingston Upon Hull  
HU1 2AA 

Dear Ms Robinson 

Re: Regulation 28 Report to Prevent Future Deaths – Colin Wiles 

We write further to your Regulation 28 Report dated 24th November 2024 and extend our condolences to 
the family of Mr Colin Wiles. Below, we address the concerns raised in points (3) and (4) of your report. 

(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive 
that day, leading to 160 hours of lost ambulance time. 

We recognise that delays in ambulance handovers have a significant impact on patient safety, timely care 
delivery, and ambulance availability for responding to community emergencies. 

On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a 
phased approach to reduce ambulance handover times: 

Phase 1:  Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire 

Ambulance Service (YAS) staff were instructed to leave. 

Phase 2:   Two weeks targeting a maximum handover time of 65 minutes. 
Phase 3:   Transitioning to a 45-minute target. 

These measures are in line with the North Bank Escalation and Surge Plan, developed by the Humber 
Health Partnership, of which the Trust is a member, and include the Ambulance Delay Protocol, which 
provides a structured framework to minimise handover delays and restore patient flow. Key actions 
undertaken include: 

1.  Ambulance Delay Protocol Activation: 

The Ambulance Delay Protocol mandates that ambulance patients should be handed over within 15 
minutes of arrival, with no patient waiting longer than 60 minutes. If a delay exceeds 45 minutes 
with no immediate plan to hand over, the protocol is triggered, requiring: 

•  Escalation to the Site Manager. 
• 

Identification and transfer of six stable patients from the Emergency Department (ED) to 
appropriate wards within 30 minutes. 

•  Priority transfer of patients with a NEWS2 score of less than 4 who do not require isolation. 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Senior Oversight and Escalation: 

The Site Team plays a critical role in monitoring capacity risks, initiating escalation protocols, and 
providing leadership to manage ambulance delays. Escalation actions are informed by continuous 
assessment of capacity and demand, with operational and clinical leadership ensuring rapid 
responses to emerging pressures. 

3.  Proactive Patient Flow Management: 

•  Revising the Standard Operating Procedure (SOP) to offload up to eight ambulances per 

• 

hour and facilitate the transfer of ten patients from the ED to inpatient wards. 
Implementing the Pull for Safety process, which establishes a regular patient flow from the 
ED to assessment areas and wards. 

•  Utilising escalation areas and reverse boarding protocols to create immediate capacity for 

new arrivals, as detailed in the policy. 

4.  Communication and Collaboration: 

•  Establishing a standardised communication protocol, including regular updates via secure 

platforms such as WhatsApp, to enhance coordination and decision-making. 

•  Engaging system partners, including YAS and Integrated Care System (ICS) colleagues, to 

expedite mutual aid and support ambulance operations. 

Since the implementation of these measures, there has been demonstrable progress in reducing handover 
times and improving patient flow. For example, the Trust’s approach to boarding patients and optimising 
escalation spaces has been instrumental in minimising the risks associated with prolonged delays. 

(4) There appears to be an issue with No Criteria to Reside (NCTR) patients and the ability to hand 
over patients into ED at Hull Royal Infirmary who arrive in emergency ambulances. 

The management of NCTR patients is a recognised challenge that directly impacts ED flow and contributes 
to ambulance handover delays. NCTR patients are identified as those who no longer meet the Criteria to 
Reside set out in the national Hospital Discharge and Community Support Guidance but remain in hospital 
due to delays in discharge pathways. 

Between March and April 2023, 20–25% of the Trust's bed base (approximately 180 beds, equivalent to six 
wards) was occupied by NCTR patients on discharge pathways 1–3. This occupancy severely impacted 
patient flow and the availability of beds for incoming ED patients. In response, the Trust has undertaken a 
series of strategic measures to alleviate these pressures.  In November 2024 the Trust implemented the 
Temporary Escalation Space (TES) and Boarding SOP, which provides a framework for managing capacity 
challenges and improving flow. 

Measures Implemented 

1.  Creation of Additional Capacity: 

•  Opened a 54-bed NCTR unit on the 13th floor of Hull Royal Infirmary to accommodate 

• 

patients awaiting discharge, reducing reliance on acute beds. 
Initiated the construction of the Rossmore Intermediate Care Centre, which will provide an 
additional 60 short-term placement beds for rehabilitation and reablement. 

2.  Formal Discharge and Flow Improvements: 

•  Collaborated with system partners to deliver a reduction in NCTR occupancy to 12.6% of the 

bed base, surpassing the national target of 15%. 
Implemented updated discharge protocols, including: 

• 

-  Enhanced cooperation with local authorities to align discharge models with available 

resources and budgets. 

 
 
 
 
 
 
 
 
 
 - 

Increased involvement of families and carers in discharge planning to ensure timely 
and appropriate placements. 

-  Use of care transfer hubs to manage complex discharges effectively. 

3.  Operational Measures from the TES and Boarding SOP: 

•  Boarding Protocols: The SOP outlines structured boarding processes to manage NCTR 

patients effectively and create capacity in the ED. This includes: 

- 

Identifying and moving up to three patients per ward to temporary escalation spaces 
(TES) or discharge lounges within 30 minutes. 

-  Ensuring timely handovers from ED to inpatient wards to free up ED spaces. 
•  Proactive Discharge Management: Board rounds and huddles on AMU and inpatient wards 
focus on early identification of patients for discharge, with targets of 30% discharges by 
12:00 and 70% by 17:00. 

•  Zero Tolerance for Delays: The SOP enforces zero tolerance for patients remaining in AMU 

for more than 24 hours or in ED for over 12 hours, ensuring flow is maintained. 

4.  Senior Oversight and Escalation: 

•  The Site Matron monitors ambulance arrivals and ED capacity in real time, triggering 

• 

escalation actions when thresholds are met. 
Issues affecting boarding or discharge are escalated to the Care Group and Site Matrons, 
with further escalation to senior leadership if unresolved. 

Impact 
These measures, underpinned by the TES and Boarding SOP, have significantly improved patient flow and 
reduced the impact of NCTR patients on acute services. Early discharge planning, effective use of 
escalation spaces, and coordinated efforts across the Trust ensure timely ED handovers and minimise 
ambulance delays. 

Conclusion 

We remain committed to addressing the concerns outlined in your report and have implemented targeted 
interventions to improve ambulance handovers and NCTR management. We are confident that these 
measures, combined with continued collaboration across the healthcare system, will reduce the risk of 
future incidents. 

If further information or clarification is required, we would be happy to provide it. 

Yours sincerely 

Group Chief Nurse