Lewis Garfield

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

Mr Hassan Shah  
Assistant Coroner for Northamptonshire   

09 December 2025 

Dear Hassan,  

Thank  you  for  the  Regulation  28  report  of  28  October  sent  to  the  Secretary  of  State  for 
Health and Social Care regarding the death of Lewis Aubrey Garfield. I am replying as the 
Minister with responsibility for urgent and emergency care.  

Firstly,  I  would  like  to  express  my  sincere  condolences  to  Mr  Garfield’s  family  and  loved 
ones. The circumstances described in your report are deeply concerning and I am grateful 
to you for bringing these matters to our attention.  

Your report raises concerns of call handler patient assessment by South Central Ambulance 
Service  (SCAS),  patient  handling  guidance  for  families,  handover  delays,  and  upcoming 
winter  pressures.  In  preparing  this  response,  my  officials  have  consulted  NHS  England 
(NHSE) and SCAS to ensure your concerns are addressed thoroughly.  I understand that 
SCAS have responded to your concerns in full. 

We acknowledge that urgent and emergency care (UEC) performance has not consistently 
met  expectations  in  recent  years.  However,  the  Government  is  committed  to  ensuring 
patients receive the highest standard of service and care from the NHS. That is why our 10-
Year Health Plan set out commitments to restoring waiting standards to those set out in the 
NHS Constitution by the end of this Parliament.   

We are taking serious steps to achieve this. We published our Urgent and Emergency Care 
Plan for 2025/26 which focuses on improvements to deliver better UEC performance both 
daily  and  during  winter  pressures,  ensuring  more  patients  receive  timely  and  clinically 
appropriate care. Key actions include: 

•  Nearly  £450  million  of  capital  investment  for  Same  Day  Emergency  Care,  Mental 

Health Crisis Assessment Centres and upgrading up to 500 ambulances 

•  Reducing  ambulance  handovers  to  a  maximum  of  45  minutes,  and  Category  2 

response times to 30 minutes on average 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 •  Enabling ambulance services to convey patients directly to non-ED facilities, such as 

• 

• 

same day emergency care services 
Improving patient flow through hospitals to 78% of patients seen in A&E departments 
within 4 hours and reducing 12-hour waits, as well as tackling discharge delays 
Increasing the number of patients receiving urgent care in primary, community and 
mental health settings 

NHSE  continues  to  work  closely  with  ambulance  trusts  including  SCAS  to  improve 
performance.  We  are  pleased  to  be  seeing  year  on  year  improvements  to  ambulance 
response times. 

• 

• 

In October 2025, the national average Category 2 response time was 32 minutes 37 
seconds compared to 42 minutes 15 seconds in October last year. 
In SCAS, the average response time was 31 minutes 54 seconds compared to 38 
minutes 30 seconds over the same time period.  

Efforts  to  reduce  ambulance  handover  delays  are  also  progressing.  NHSE  continues  to 
collaborate  locally  with  ambulance  trusts  including  SCAS,  Integrated  Care  Boards,  acute 
trusts and regional teams. These efforts aim to ensure safe and timely patient handovers, 
freeing up crews to respond to emergencies in the community.  

• 

In October 2025, the average handover delay nationally was 31 minutes 19 seconds 
compared to 40 minutes 20 seconds in October last year. 

•  SCAS’s average hospital handover time has improved  to 19 minutes 47 seconds 

from 31 minutes 6 seconds between October 2024 and 2025. 

Regarding your concerns for the upcoming winter, we have implemented additional surge 
capacity, increased staffing, and enhanced coordination across services to mitigate 
seasonal pressures. This includes running stress test exercises and offering health checks 
to the most vulnerable. 

We will continue to monitor performance closely and work with SCAS and NHSE to ensure 
sustained improvement. I hope this response provides reassurance that the Government is 
taking meaningful action to improve urgent and emergency care services. Thank you once 
again for bringing these concerns to my attention.  

Yours sincerely, 

MINISTER OF STATE FOR HEALTH

Confidential  

Mr Hassan Shah, Assistant Coroner 
for the coroner area of 
Northamptonshire. 

Trust Headquarters 
1 Horizon Place 
Mellors Way 
Nottingham Business Park 
Nottingham 
NG8 6PY 

Dear Mr Shar 

Re: Report regarding the case of  Mr Lewis Aubrey GARFIELD deceased.  

I am writing to you in response to the concerns that you highlighted to the 
Trust following the inquest hearing into the sad death of Lewis Aubrey 
Garfield that concluded on 27th October 2025.  

Thank you for raising the concerns regarding the delays at the hospitals which 
is contributing to the Trust being able to respond to patients waiting in the 
community like Mr Garfield.  

I am aware that you will share my response with Mr Garfield’s family, and I 
firstly wish to express my sincere condolences to them.  

EMAS core purpose is to respond to patient needs in the right way, developing 
our organisation to become outstanding for patients and staff, and 
collaborating to improve wider healthcare.  We will deliver safe, effective, 
compassionate care for patients, embedding a culture of compassion, 
continuous improvement. 

East Midlands Ambulance Service (EMAS) acknowledges the concerns raised by 
HM Coroner and I offer the following clarifications and commitments. 

The concerns highlighted in your report have been reviewed and discussed by 
the Trust’s Incident Review Group, which routinely considers issues raised 
through inquests and Prevention of Future Death reports. This process ensures 
that lessons are identified and appropriate actions are taken to address any 
systemic or procedural shortcomings. 

Page 1 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Matters of Concerns raised on 28 October 2025 

a)  I understand that nationally, the target time for handover from 

ambulance to hospital staff is 15 minutes. In the present case, the 
handover from ambulance to nursing staff at John Radcliffe Hospital 
took 25 minutes. However, at the same time, the longest handover time 
at Northampton General Hospital was 5 hours and at Kettering General 
Hospital it was 7 hours. The Trust lost 115 hours waiting to handover at 
Northampton over 121 hours at Kettering. 

b)  I heard evidence that steps are being taken to mitigate the impact of 

pressures in the healthcare system. University Hospitals of 
Northamptonshire have adopted the ‘45-minute handover’ approach. 
Despite this, on the day of the inquest on 27 October 2025, average 
handover times at Northampton General Hospital were 1 hour 11 
minutes and I suspect that this will get worse during the full onset of 
winter pressures.  

Persistent delays across the system have led to the introduction of an 
additional operational measure known as the 45-minute handover ceiling. This 
is also in this year’s 2025/26 planning guidance and Urgent Emergency Care 
recovery plan. Under this policy, if a patient has not been formally handed over 
within 45 minutes, ambulance crews are required to complete a safe transfer 
process and leave the patient in the care of hospital staff. This includes 
ensuring the patient is placed in an appropriate location (such as a trolley, 
chair, or designated waiting area) and that essential clinical information is 
communicated to ED personnel. The purpose of this measure is to prevent 
excessive delays that compromise ambulance availability and community 
response times for life-threatening incidents. 

It is important to note that this policy does not permit abandonment of care, 
hospitals assume clinical responsibility for patients from the point of arrival or 
after 15 minutes, whichever is sooner. The 45-minute ceiling is therefore a 
pragmatic safeguard to balance patient safety with system resilience, though it 
can increase corridor care and crowding pressures within EDs. 

These figures highlight a significant systemic issue affecting patient flow and 
ambulance availability, with extreme delays at some sites creating substantial 
operational pressures and potential risks to patient safety. 

Kettering General Hospital and Northampton General Hospital now operate 
under the United Hospitals of Northamptonshire (UHN). The EMAS senior 
leadership team in Northamptonshire has established a strong collaborative 
relationship with the senior team at UHN and the Integrated Care Board (ICB). 

Page 2 of 3 

 
 
 
 
 
 
 
 
 This partnership ensures we work closely to manage risk across both acute 
sites, as well as for patients waiting in the community. 

Within the Northamptonshire division, the Trust are now implementing 
dynamic strategic conveyance on a daily basis, directing patients to hospitals 
outside their usual catchment area when necessary. This approach helps 
mitigate the impact of excessive handover delays at pressured acute sites, 
reducing lost time and enabling crews to return promptly to attend patients in 
the community. 

The Trust continues to work in close partnership with the Acute Trust, the ICB, 
and NHS England to implement the 45-minute handover protocol. While an 
exact implementation date has not yet been confirmed with the Acute Trust, 
we are actively progressing toward a target of mid-December 2025. To support 
this, weekly implementation meetings facilitated by NHS England commenced 
on 27th November, ensuring collaborative oversight and alignment across 
Northamptonshire. 

The Trust proactively initiates ‘rapid handover’ requests during periods of high 
demand, particularly when multiple hospital handover delays coincide with 
uncovered Category 2 emergency calls. These actions are guided by our 
‘Managing Delays in the Safe Handover of Patients’ Standard Operating 
Procedure, which incorporates a series of triggers aligned with the NHSE 
Midlands Region agreed process. 

Requests for rapid and immediate handover requests are recorded by our 24/7 
on duty command teams, captured within our daily operational log. This 
supports the triggering of further escalation actions that may be required 
should these handover request be declined by the hospital.     

Our priority is to provide safe, high-quality care for our patients. We’re working 
closely with system partners to reduce the impact of delays on patients and 
staff, including implementing the national 45-minute maximum ambulance 
handover time standard.  

I trust this response provides you with clear assurance of our unwavering 
commitment to reducing hospital handover delays and driving continuous 
improvement across our services.  

Yours sincerely  

Chief Executive  

Page 3 of 3

South Central Ambulance Service NHS Trust 
Unit 7 & 8 Talisman Business Park 
Talisman Road 
Bicester, Oxon 
OX26 6HR 

PRIVATE AND CONFIDENTIAL 
Mr Hassan Shah 
Assistant Coroner for Northamptonshire 

4th November 2025  

Dear Mr Shah, 

I am writing to you in response to the concerns that you highlighted to the Trust following the 
inquest hearing into the sad death of Lewis Aubrey Garfield that concluded on 27th October 
2025. Thank you for providing us with the opportunity to respond to your concerns.   

At the outset I would like to offer my personal condolences to Mr Garfield’s family and friends.  

To confirm, your Regulation 28 report relates to six concerns labelled ‘a)’ – ‘f)’ in your report. 
The report has been written to four recipients and the concerns which relate to the involvement 
of South Central Ambulance Service (SCAS) are points ‘a)’ and ‘c)’: 

a)  It was not clear if information about the symptoms taken by SCAS was adequate or if 
it had been recorded or conveyed by them accurately/completely. It was odd that the 
call was upgraded to category 2, just 14 minutes after being designated a category 3, 
without any evidence that there had been a change or deterioration.  

c)  The family complained of not being given any guidance on how to deal with the patient 
pending the arrival of an ambulance e.g. not to move him given the fall down the stairs. 

I understand from your report that the court had been made aware of concerns that had been 
raised by Mr Garfield’s family in advance of the hearing and it is regretful that evidence was 
not requested from the Trust  in  response to  these concerns  as  would usually  be the  case. 
Moving forward, we would be grateful for the opportunity to address any concerns regarding 
our involvement in a patients care pathway and participate in the inquest hearing if a written 
response is not sufficient.  

Actions taken when a 999 call is received 

Before  answering  the  concerns  in  detail,  it  may  be  helpful  if  I  explain  how  the  emergency 
ambulance  service  operates  and  interacts  with  other  service  providers  by  way  of  context. 
Patients and callers contacting the 999 service are assessed by a non clinical member of staff 
who  has  been  trained  to  utilise  a  clinical  decision  support  software  system  called  NHS 
Pathways. This has been licensed by NHS England (NHSE) for use by UK ambulance and 
NHS 111 services.  NHSE also own and manage the software system and are responsible for 
authoring the embedded algorithms used during the assessment.  

When the assessment has been completed, the patient is signposted to the most appropriate 
care  pathway  for  their  clinical  condition  based  on  the  information  provided  during  the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 assessment. This could be an ambulance response or could include for example referral to a 
GP out of hours services within a clinically safe timeframe, for that service to deliver onward 
care  and  /  or  advice.   Additionally,  patients’  symptoms  can  also  be  managed  by  the  caller 
receiving advice on accessing an alternative care pathway such as seeing their GP, attending 
a walk-in centre or minor injury/illness unit or self-care. 

If  the  assessment  has  identified  that  an  emergency  ambulance  response  is  required,  the 
national ambulance response standards determined by NHSE are in the table below: 

National Ambulance Call Categories  
CATEGORY 1 - LIFE-THREATENING CONDITIONS  
Time  critical  life-threatening  event  needing  immediate 
resuscitation  e.g.  cardiac  or 
intervention  and/or 
respiratory  arrest,  airway  obstruction, 
ineffective 
breathing, unconscious with abnormal or noisy breathing.  
CATEGORY 2 - EMERGENCY CALL  
Potentially  serious  conditions  that  may  require  rapid 
assessment,  urgent  on-scene intervention  and/or  urgent 
transport e.g. probable heart attacks, strokes, and major 
burns. 
CATEGORY 3 - URGENT CALL 
Urgent problems that are not immediately life-threatening 
which  need  treatment  to  relieve  suffering  (e.g.  pain 
control)  and transport,  or  assessment  and  management 
at scene with referral where needed. In some instances, 
ambulance  personnel  may  treat  patients  in  their  own 
home  or  refer  patients  onward  to  an  appropriate  Health 
Care Professional. 
CATEGORY 4 - NON-URGENT CALL  
Problems that are not urgent but need clinical assessment 
(face-to-face or telephone) and possibly transport within a 
clinically appropriate timeframe.  

Response Timeframe  
We  are  required  to  respond 
within  an  average  time  of  7 
minutes and  at  least  9 out  of 
10  occasions  within  15 
minutes 
We  are  required  to  respond 
within  an  average  time  of  18 
minutes and  at  least  9 out  of 
10  occasions  within  40 
minutes 
We are required to respond to 
calls  of  this  nature  at  least  9 
out of 10 occasions within 120 
minutes 

We  are  required  to  provide 
clinical assessment at least 9 
out of 10 occasions within 180 
minutes 

Review undertaken in June 2025. 

On 5th June 2025 the Head of Patient Safety at East Midlands Ambulance Service wrote to 
the Trust and asked us to review our involvement in Mr Garfield’s care pathway. Requests like 
this are common within the NHS where a patient has died or had a poor outcome. The patient 
safety culture within the NHS prompts Trusts to work together to review care episodes so that 
any areas where service delivery and / or patient safety could be enhanced are identified and 
acted upon.  

A  copy  of the response that  we  sent to East  Midlands Ambulance Service,  which answers 
point ‘a)’ of your concern, is enclosed with this letter. Had the court sought evidence from the 
Trust for the inquest hearing, a copy of the response would have been provided along with a 
bespoke statement detailing a full review of the interactions we had with the family.  

A  full  summary  of  the  calls  we  took  is  detailed  below  which  includes  details  regarding  the 
content and categorisation of the 999 calls. This section also covers point ‘c)’ of your concerns.    

Call one 

SCAS received the first 999 call from Mrs Garfield at  00:30:57 on 4th December 2024.  Mrs 
Garfield  was  using  a  mobile  telephone  and  unfortunately  due  to  poor  reception,  the  line 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 became disconnected before the triage could begin. Our Emergency Call Taker confirmed the 
telephone  number  with  the  BT  Operator  and  telephoned  Mrs  Garfield  back.  Mrs  Garfield 
explained that approximately 10 minutes earlier, she had found her husband on the floor at 
the bottom of the stairs. When asked, Mr Garfield said that he had not fallen down the stairs, 
but Mrs Garfield advised this may not be correct because he had dementia. It was reported 
by Mrs Garfield that she thought  her husband had injured his head and back, and with the 
assistance of their neighbour, they had ‘got him up’.  

The Emergency Call Taker was unable to fully triage the call  because Mr and Mrs Garfield 
were unable to answer the triage questions with any accuracy. Their neighbour came onto the 
call and was able to confirm that Mr Garfield was not bleeding heavily.  

NHS Pathways provides you with three options to answer the questions asked, ‘yes’, ‘no’ and 
‘not sure’. When an Emergency Call Taker receives more than two ‘not sure’ answers, the call 
is classed as complex, and they need to seek advice. The Emergency Call Taker did so on 
this occasion and was advised to select ‘triage not possible’ within the NHS Pathways system 
to reach an ambulance response disposition. Where there are no confirmed reports of major 
trauma or heavy bleeding, the default category of ambulance response is a Category 3.  

In relation to worsening advice, our Emergency Call Taker correctly advised that Mrs Garfield 
and her neighbour keep a close eye on Mr Garfield and they should apply pressure to his head 
wound  if  it  begins  to  bleed  again  and  should  not  remove  any  objects  from  the  wound.  In 
addition to this, the Emergency Call Taker advised them to redial 999 if his condition changed, 
worsened or they had any other concerns.  

This call was audited by our Audit and Investigation team and was found to meet the standards 
expected by NHS Pathways and the Trust.  

Call two 

This second call was received by SCAS at  00:50:27. Mrs Garfield was calling for a second 
time because Mr Garfield had fallen again whilst they were trying to help him to the toilet. She 
explained that his condition had become worse since this second fall and she reported that he 
had  injured  his  shoulder,  back  and  head.  Mrs  Garfield  explained  that  his  head  was  not 
bleeding heavily, and she had placed a dry dressing on it. When asked whether Mr Garfield 
was breathless, his wife replied that he was, but he was not struggling desperately for every 
breath. Mrs Garfield passed the telephone to her neighbour so they could provide additional 
information  to  the  Emergency  Call  Taker.  Their  neighbour  confirmed  that  he  had  got  Mr 
Garfield off the floor, and he was now sat in a chair.  

This call reached a Category 2 ambulance response due to the reported breathlessness. Mrs 
Garfield was advised not to move Mr Garfield unless he was in immediate danger where he 
was and informed that she should redial 999 if his condition changed, worsened or she had 
any further concerns.  

This  call  was  also  audited  and  was  regrettably  found  to  be  non  complaint  with  expected 
standards. The triage had reached the correct category of response, but the Emergency Call 
Taker did not pass on location information to East Midlands Ambulance Service and answered 
one of the questions incorrectly. Although the answer she received was that Mr Garfield would 
not be able to get himself off the floor unaided, because he was already sitting in a chair, the 
Emergency Call Taker should have selected the ‘yes’ answer stem within the NHS Pathways 
system.  

The Emergency Call Taker had a face to face meeting with the auditor and her line manager 
to discuss the audit outcome on 11th June 2025. They had the opportunity to listen to the call 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and were provided with training material to ensure that they understood the errors they had 
made and so that their future practice improved moving forwards.  

Call three 

A third 999 call was received by SCAS from Mr Garfield’s neighbour at 01:38:31. His neighbour 
confirmed that Mr Garfield’s condition remained the same and he was just calling to request 
an update regarding when an ambulance would arrive. The Emergency Call Taker explained 
to the caller that she was unable to provide him with an estimated time of arrival because he 
was not talking to the ambulance service that would be sending a crew to Mr Garfield. The 
Emergency Call Taker advised the caller to apply pressure to Mr Garfield’s head wound with 
a clean dry cloth if his head was still bleeding and to call again if his condition changed or 
worsened. East Midlands Ambulance Service were advised that a third call had been received. 

An audit of this call confirmed that it was triaged correctly and in line with expectations and 
processes. 

Call four 

At  02:29:18  a fourth 999  call  was  received from Mrs Garfield.  She  explained  that  they  had 
been waiting for 2 hours, and Mr Garfield kept asking when an ambulance would arrive. The 
Emergency Call Taker asked whether his condition had changed, and Mrs Garfield explained 
that his speech was now very confused. She confirmed that Mr Garfield had been ‘got up’, 
was propped up on a sofa in the hallway and was being kept warm with blankets and coats 
placed over him. Because of the reported change in his condition, a further triage took place. 
Mrs Garfield confirmed that the bleeding from his head wound had stopped but he was still 
breathless. She said that she was now the only person who was with Mr Garfield. The triage 
resulted in a Category 2 ambulance response which was passed to East Midlands Ambulance 
Service. 

The Emergency Call Taker advised Mrs Garfield not to move her husband further unless he 
was in immediate danger and explained Mr Garfield should be allowed to adopt a position that 
is comfortable for him. She was further advised not to remove any false teeth and to roll Mr 
Garfield  onto  his  side  if  he  became  unconscious  before  redialling  999.    Mrs  Garfield  was 
informed that she should call 999 again if Mr Garfield’s changed worsened or she had any 
further concerns.  

This  call  was also found  to  be  compliant  with  expected  standards  and  reached  a  safe and 
appropriate outcome based on Mr Garfield’s presentation at the time of the call. 

Call from a clinician  

Because the clinician who made the call to Mrs Garfield referred to within your Regulation 28 
report works for East Midlands Ambulance Service SCAS are unable to comment on the call 
or  their  rationale  for  upgrading  the  call  to  a  Category  1  ambulance  response.  We  are  also 
unable to comment on the time that passed before a clinician reviewed the call. East Midlands 
Ambulance Service will need to respond to both of these points.  

Response to concerns 

I have asked the SCAS legal team to provide you with copies of call recordings for the calls 
that were taken so that you can be satisfied that the information captured during the call triage 
was  accurate.  It  is  evident  from  the  second  999  call  that  there  had  been  a  change  and 
deterioration in Mr Garfield’s condition, and he had unfortunately fallen again after the first 999 
call was made. The Emergency Call Taker was also able to obtain answers to the questions 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 asked during the assessment in the second 999 call. The symptoms Mr Garfield was suffering 
from since his second fall and the ability to obtain accurate answers during the triage is the 
reason why the outcome of the second 999 call was different to the first call.  

In relation to advice provided regarding moving Mr Garfield, it is clear from the call recordings 
that Mr Garfield had already been moved from the floor onto a sofa following each fall before 
999 was called. Our Emergency Call Takers correctly advised his wife and neighbour not to 
move him any further unless he was in immediate danger. This advice is provided to prevent 
the possibility of further injury being caused before a physical examination can rule out any 
injuries caused by the fall which could be worsened on movement.  

I hope that this letter has adequately addressed the concerns that  you have raised. Should 
you wish to discuss these matters further, please contact Jennifer Saunders, Head of Legal 
Services at SCAS who will be able to facilitate this. 

Yours sincerely, 

Chief Executive 

Enc 

Response to East Midlands Ambulance Service 
Call recordings 

5

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 PRIVATE & CONFIDENTIAL 

Claire Kelman 

Southern House 
Sparrowgrove 
Otterbourne 
Winchester 
SO21 2RU 

 3rd July 2025 

Dear Ms Kelman 

I am writing further to your email to our Patient Experience Team on the 6th June 2025, in which 
you raised a concern regarding our Emergency 999 service, specifically the incident involving 
Lewis Garfield on 4th December 2024. I am now able to respond following a full review by the 
Collation of Facts Manager, Amy Harman, Senior Emergency Call Taker. 

Firstly, I would like to offer my sincere apologies for any upset and distress caused as a result of 
this incident involving Mr Garfield.  

Before answering your concern in detail, it may be helpful to explain how the emergency 
ambulance service operates and interacts with other service providers. Patients and callers 
contacting the service are assessed by an Emergency Call Taker (ECT) who is not clinically 
trained utilising a Clinical Decision Support Software system called NHS Pathways. This has been 
licensed by NHS England (NHSE) for use by UK ambulance services.   

Please find below the information requested in relation to the concerns raised regarding the call 
activity involving Mr Lewis Garfield on Wednesday, 4th December 2024. 

Included is a detailed timeline of the patient’s journey through our Emergency Operations Centre 
(EOC), the outcomes of all relevant call audits, and responses to your specific queries. 

Timeline and Call Overview 

00:30:57 – Amy can confirm this was the first 999 call received by South Central Ambulance 
Service (SCAS). This call was triaged by an ECT. The caller reported the patient had been found 
at the bottom of the stairs with injuries to his head and back. The patient, who had dementia, 
denied falling down the stairs. Due to the caller being unable to provide enough clinical detail to 
support a full triage, the call was coded as "triage not possible" per NHS Pathways protocol.  

00:44:49 – A Category 3 ambulance request was sent to EMAS via ITK 
Audit Outcome: Compliant with NHS Pathways standards. 

. 

Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2
00:50:27 – Second 999 call received. The patient’s condition was reported to have worsened, with 
mention of a potential shoulder injury and increased breathlessness. A neighbour, identified as a 
GP, had assisted the patient into a chair. 

00:58:34 – A Category 2 ambulance request was sent  to EMAS via ITK 
Audit Outcome: Non-compliant due to the factors listed below. 

  The ECT incorrectly recorded the patient as unable to get off the floor. 
  Additional location information that could assist the attending crew was not relayed. 

Despite these learning points, the audit found that the overall triage category and response 
priority  were unaffected and a safe an appropriate outcome was reached, based on the Mr 
Garfield’s presentation at the time of the call. 

The learning points from the audit were addressed through a face-to-face debrief with the ECT, 
supported by a Call Review Plan and Reflective Practice Exercise. Further support has been 
offered to ensure learning is embedded. 

01:38:31 – Third call received from the patient’s neighbour requesting an ETA. No change in 
clinical condition was reported. 

01:48:06 – ETA request was manually passed to EMAS. 
Audit Outcome: This call was compliant with the expected standards and processes. 

02:29:18 – Fourth call received. The patient’s wife reported new confusion and increasing 
breathlessness, though the head wound had ceased bleeding. 

02:33:10 – A further Category 2 ambulance request was made via ITK to EMAS (reference: 
19152499). 
Audit Outcome: This call was also compliant with the expected standards and processes. A safe 
and appropriate outcome was reached based on the patient’s presentation at the time of the call. 

Call Audit Summary 

  Three of the four calls were triaged in accordance with NHS Pathways protocols and SCAS 

procedures. 

  One call (second) was found to be non-compliant due to errors in documentation and 

omission of supplementary information. However, this did not alter the disposition or call 
category. 

  Corrective action has been taken and learning has been shared directly with the call 

handler. 

Call Cycle Summary 

Each contact received by the EOC was appropriately escalated via ITK to EMAS. Calls were 
handled in line with NHS Pathways guidance and SCAS policy, with the exception of the isolated 
deviation outlined above. 

The investigation of complaints and feedback form an important part of organisational learning and 
service development which contributes to the aim of providing a consistently high quality of service 
to patients, so I would like to thank you for supporting this process. 

I would also like to thank you for providing us with the opportunity to address your concerns and I 
hope that you are reassured and satisfied with the response given.  If you have any further queries, 
please do not hesitate to contact the Patient Experience Team.    

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Senior Patient Experience Officer 

3

Kettering General Hospital               

Rothwell Road 
Kettering 
Northants NN16 8UZ 

Confidential 

11th December 2025                                                                        

Mr Hassan Shah 
Assistant Coroner for Northamptonshire                                   
The Guildhall                                                                              
St Giles Square 
Northampton 
NN1 1DE 

Dear Mr Shah 

Regulation 28: Report to prevent future deaths re Mr Lewis Aubrey Garfield 

I write in response to the above report issued on 28th October 2025 to University Hospitals 
of Northamptonshire NHS Group (UHN).   

I would like to firstly express my sincere condolences to the family of the late Mr Garfield 
and to acknowledge and apologise for the delayed ambulance handover times noted at the 
inquest on 27th October 2025. 

This response to the Regulation 28 Report builds on the previous information provided on 
actions being taken to mitigate the impact of pressures in the healthcare system and our 
adoption of the “45 minute handover” approach. 

Ambulance Handover Improvement Planning Update 4th Dec 2025 

It is recognised 2024/25 was one of the most challenging years for delivery of urgent and 
emergency care within Northamptonshire and its hospitals.  Long ambulance delays 
impacted both delivery of urgent care across the Emergency Department with average 
handovers of 84mins in Dec-24 and impact on Cat2 ambulance response with up to an 
average response time of 111mins in Dec-24.  

Since January 2025 University of Northamptonshire Hospitals (UHN) have worked through a 
UEC improvement programme in collaboration with support from NHS England and Getting 
it  Right  First  Time  (GIRFT)  team  to  improve  delivery  of  the  UEC  pathway  and  reduce 
ambulance handover delays.  This included a Trust and system partner commitment across 
ICB, Local Authorities, EMAS and NHFT to winter preparedness commencing much earlier 
in the year following lessons learnt.  Key winter schemes developed in the UHN Winter Plan 
were approved through Trust Board on 1st August 2025.  UEC improvements have focused 
on safety within the Emergency Department(s), utilising alternative strengthened pathways 
to ED and improvement in admitted patient flow through reduction in length of stay. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ambulance Handover Performance 

Overcrowding in the Emergency Department is well recognised as impacting on quality and 
safety, increasing risk of harm to patients if unable to handover from ambulances.  This risk 
is  actively  monitored  through  the  Trust  Accountability  Framework  with  performance  and 
actions  reviewed  through  Divisional  Accountability  meetings,  Clinical  Quality  and  Safety 
Committee in Common, Trust Board and ICB UEC Board.  In line with this year’s 2025/26 
planning guidance and Urgent and Emergency Care Recovery plan a 45min handover ceiling 
has been worked towards in close collaboration with EMAS colleagues both at Directorate 
and Director level.   

Ambulance handover performance both in terms of average handover times and compliance 
against max 45min handovers has improved throughout the year, see figure 1.   

Figure 1.  Data source: Ambulance and NHS111 Commissioning Team, Derby ICB 

It is also important to reflect on the Nov-25 against Nov-24 position, particularly in the context 
of a YTD position of 5% increase in conveyances against plan.  

Northampton 

Nov-24 
82mins 
47% 
86mins 
49% 
Data source: Ambulance and NHS111 Commissioning Team, Derby ICB 

Performance Metric  
Average handover time 
% Handovers achieved in <45 mins  
Average handover time 
% Handovers achieved in <45 mins  

Kettering 

Nov-25 
28mins 
88% 
32mins 
87% 

Variance 
-54mins 
41% 
-54mins 
38% 

2 

 
 
 
 
 
 
 
 
 
 
 Summary of Key Actions Taken 

Transformation and Strategic Developments  

As of Monday 3rd November at NGH, a new purpose built Rapid Assessment Unit (RAU) 
was commissioned providing 8 additional trolley spaces aimed at handover within 15mins 
into a dedicated space for primary assessment of patients.  This forms a key part of 
strategic planning that will see a new Urgent Treatment Centre open from July 2026 with 
works already having commenced.   

The UTC facility will provide a consolidated single front door for walk in patients seeking 
emergency care with rapid assessment and triage of patients with the ability to take direct 
ambulance referrals from co-located facilities.  

In commitment of reducing handover delays the identify of Nye Bevan wards have been 
formalised with a new dedicated Acute Assessment Unit (AAU) on Walter Tull with Esther 
White ward being 72hr medical short stay.  This key improvement in patient pathway has 
enabled suitable patients to be identified within the RAU and streamed directly into the AAU 
reducing the demand into the ED further reducing handover delays.  This is a key 
improvement in the way patient care is being delivered to improve the patient experience 
through reducing delays in ED and seeing medical patients in the right location at the right 

3 

Date Action Implemented Impact Mar 2025 Implementation of a standardised Transfer of Care (TOC) form across UHN. Improve quality and reduce delays associated with TOC referrals into the discharge hub. Mar 2025 Frailty SDEC go live KGH. Dedicated capacity for Frailty SDEC service.  Mar 2025 Agreement of Internal Professional Standards across UHN.  Expectations on timeliness of speciality support and escalation.  Apr 2025 Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge.  14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.  Apr 2025 Formalised direct to SDEC pathways for EMAS and extended operating hours. 15% increase in SDEC activity to reduce ED attendance and overcrowding. Apr-May 2025 Boardround test for change and Boardround SOP (NGH). Improved discharge planning and boardround documentation.  May 2025 Release to Respond Go live NGH. Implement release to respond model with key escalation triggers to balance clinical risk across the organisation. June 2025 NyeBevan move to medicine speciality only and address backflow of patients with GIRFT.  Reduced LoS on NyeBevan with reduced medical outliers in surgical wards. July 2025 Use of Siren to review patient identifiable information from EMAS pre arrival.  Reduce delays associated with registration of patients into EPR. Sept 2025 Twice weekly system partner escalation calls for complex discharge support.  Improvement in super stranded position across UHN. Oct 2025 Cardiology Virtual Ward launched at NGH. Reduce length of stay through virtual monitoring of heart failure patients who would otherwise meet criteria to reside. Oct 2025 Frailty SDEC go live NGH.  Frailty team based in medical SDEC for speciality assessment. Oct 2025 Trusted Assessor introduced at NGH. Reduce discharge delays for patients returning to care homes.  Nov 2025 Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand. Dec 2025 Introduction of nerve centre pre arrivals screen  Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.   
 
 
 
 
 
 time. This has provided a step change of ~3% improvement in 12hr performance within the 
ED and reducing overcrowding alongside a reduced requirement to use ED temporary 
escalation capacity.    

Digital Enabler 

Since July 2025, both sites have actively engaged in access and review of patient 
information documented by EMAS crews for patients who are inbound (Siren EPR).    

Through the development of NerveCentre at NGH site - a pre arrivals screen is now 
available from 1st December. This has been a key digital enabler for the ED team to input 
clinical history directly into NerveCentre ahead of the crew arriving to site, rather than 
having to book in when the crew arrive.  This will further improve <15mins handover time.  

Our priority is to provide safe, high-quality care for our patients. We are working closely with 
our system partners across the ICB, Local Authorities, EMAS and community partners from 
Northamptonshire Healthcare NHS Foundation Trust, to further reduce the impact of delays 
on patients and staff, including implementation of the national 45-minute maximum 
ambulance handover time standard.  

I trust that the above information details our commitment to improve patient safety by 
continuously working to meet and maintain the national standard. 

Yours sincerely 

Medical Director, UHN 

4