PFD report

Kyriacos Athanasis · Prevention of Future Deaths report

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Issued 6 Jan 2022•Norfolk

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
31

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Lack of emergency department capacity for timely ambulance patient transfer
    Part of recurring concern: Insufficient emergency-department capacity for timely patient care
  2. Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
    Part of recurring concern: Delays in ambulance-to-hospital patient handoverPart of recurring concern: Failure to maintain safe hospital patient flowPart of recurring concern: Failure to provide timely hospital admissionPart of recurring concern: Insufficient emergency-department capacity for timely patient care
  3. Limited capacity for diagnosis and treatment while patients wait in ambulances
    Part of recurring concern: Insufficient emergency-department capacity for timely patient care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.21

  1. Action

    Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  2. Action

    Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. Action

    Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of emergency department capacity for timely ambulance patient transfer

Wider context from the report

“(1) Evidence given at the inquest revealed that there was a delay in Mr. Athanasis being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain emergency department and inpatient capacity for timely ambulance admissions

Wider context from the report

“(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover; Failure to maintain safe hospital patient flow; Failure to provide timely hospital admission; Insufficient emergency-department capacity for timely patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited capacity for diagnosis and treatment while patients wait in ambulances

Wider context from the report

“(5) Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40). There are clear risks of future deaths for patients waiting for an ambulance as well as to patients whose diagnosis and treatment is delayed due to limited intervention being available in the back of an ambulance. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient safety checks to reveal the extent of injuries in patients left in ambulances

Wider context from the report

“(3) In this instance the mechanism to undertake a safety check was not sufficient to reveal the extent of the injuries Mr. Athanasis had sustained, and this meant there was a delay in diagnosing him with his unstable cervical fracture. This delay in conjunction with other issues more than minimally or trivially contributed to his death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in ambulances attending other emergencies

Wider context from the report

“(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Reliance on safety checks for patients left in ambulances because of emergency department space delays

Wider context from the report

“(2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care; Unsafe emergency-department crowding leaving patients without appropriate clinical space.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.

Verbatim wording from the response

“Since May 2022 the ICB has supported all 3 acute hospitals within our system, including the JPUH, to further develop and expand its GP Streaming Unit which provides a pathway for ED staff to assess patient needs on arrival and ensure that those who are more suitable for GP care can attend the unit co-located within the department. This helps to create flow and promote more prompt clinical assessment.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.

Verbatim wording from the response

“In addition to the above, the ICB has continued to support provider-level actions to increase oversight of patients in waiting ambulances, enabling collaboration between ambulance and hospital providers to put in place new ways of working to maintain patient safety, that transcend traditional organisational responsibilities. For example, this includes a ‘pit-stop’ assessment model that came into effect at JPUH in June 2022, which enables early diagnostics to be commenced for patients before they enter the ED. This initiative was supported by the use of additional temporary staff including the use of reservists, additional bank staff and medical”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.

Verbatim wording from the response

“Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.

Verbatim wording from the response

“The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.

Verbatim wording from the response

“However, since August 2022 the NHS has released additional money for investment in discharge resources. In the first allocation the Norfolk and Waveney system was awarded £9m revenue and £2m capital, which was invested in new health and social care beds and community packages of care creating the equivalent of approximately 250 beds. In mid-November 2022 the government announced a further £500m fund for health and social care, of which our system share was approximately £11m which is currently being used to commission additional care and support services to further ease the burden on hospital beds. A third award was announced in January 2023 providing a further £3.74m revenue to be spent by 31st March 2023.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.

Verbatim wording from the response

“The ICB is coordinating the system Discharge Programme which brings providers together to collaborate on the utilisation of this money; jointly planning, delivering, and monitoring improvement actions, including:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.

Verbatim wording from the response

“nationally. We continue to follow the national NHS Operational Pressure Escalation Level Framework to identify, escalate and respond to flow pressures across our system. The ICB continues to coordinate a programme of local improvement, which is built optimising and utilising the funding we have been allocated, to focus on the following local priorities:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.

Verbatim wording from the response

“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deploy additional ambulance resources across the three acute trusts to cohort suitable patients and release community response capacity.

Verbatim wording from the response

“Additionally, in order to effect earlier release of ambulance resources into the community, additional ambulance resources have been utilised across all three Acute Trusts to enable cohorting of suitable patients, thereby releasing ambulance resources. Whilst this does not address directly, ambulance handover times it does improve the safety of patients within the community who would otherwise face longer waits for ambulance attendance. This is supported by established frameworks which identify the scope of clinical practice of the available hospital staff members and is further supported by provider and system level escalation frameworks such as the OPEL and critical incident management framework.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver the Leading for System Change project to identify and address system-wide discharge barriers.

Verbatim wording from the response

“The ICB has also placed senior clinical staff in to our three Acute Hospitals for focussed periods of on-site support, to support the management of escalations in a timely manner. Not only does this provide additional operational support to frontline colleagues, utilising ICB staff experience, it also improves ICB oversight and assurance, enabling the ICB to actively reflect on the operational impact that their system-level interventions (as described above) are having on patients and the staff delivering their care. The Norfolk and Waveney ‘Leading for System Change’ project launched in 2022, bringing together key colleagues involved in discharge across the Integrated Care System (ICS) with a focussed remit to understand, mitigate and rectify some of our underlying problems as a system which include:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.

Verbatim wording from the response

“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.

Verbatim wording from the response

“The ICB coordinated systemwide adoption in October 2022 of the Professional Standards of Care for Patients Waiting in Ambulances to ensure patients awaiting handover to ED receive consistent, timely and clinically appropriate care, and that processes are in place to rapidly identify and escalate care needs for deteriorating patients. The ICB continues to monitor compliance with these standards, through daily system calls and discussion with site teams, as well as focused on-site quality visits.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.

Verbatim wording from the response

“The ICB has focussed resources into the expansion of Same Day Emergency Care (SDEC) provision across all acute hospital sites as an alternative to ED attendance. This is an additional service which provides an alternative pathway for patients who require diagnostics and assessment, which can be undertaken without an overnight stay or prolonged hospital attendance.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor and support completion of the hospital spinal-referral review and clinical-governance learning actions.

Verbatim wording from the response

“Action 2: Hospital to undertake a review of their spinal referral process and develop a new Standard Operating Procedure to supplement their existing clinical guidelines. Progress: Action to be completed by the end of March 2023. ICB will monitor and provide any support required.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 6 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.

Verbatim wording from the response

“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide additional ambulance funding to expand capacity and deliver new ambulances.

Verbatim wording from the response

“We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide 5,000 additional staffed permanent hospital beds.

Verbatim wording from the response

“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Scale up virtual ward capacity beyond its existing level.

Verbatim wording from the response

“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver six new ambulance hubs to reduce handover delays.

Verbatim wording from the response

“We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish Same Day Emergency Care services across every hospital with a major emergency department.

Verbatim wording from the response

“In addition, Same Day Emergency Care (SDEC) services will be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients receiving SDEC can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.

Verbatim wording from the response

“We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.

Verbatim wording from the response

“The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.

Verbatim wording from the response

“Nationally, the NHS stopped the Hospital Discharge Fund on 31 March 2022, which had essentially funded 4 weeks of ‘free care’ to support patient discharge, regardless of who was responsible for commissioning this care and which also paid for a large range of services and beds. This meant that on 1st April the Norfolk and Waveney system lost funding for”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.

Verbatim wording from the response

“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Place senior clinical staff in the three acute hospitals for focused operational support, oversight and assurance during escalations.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  2. 2

    Coordinate regional system-level learning through the urgent and emergency care serious-incident tactical group and feed recommendations into improvement plans.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. 3

    Establish the virtual Open Room as a substantive service to divert suitable 999 callers to alternative community pathways.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  4. 4

    Continue commissioning the Mental Health Joint Response Car to provide home-based mental-health triage and follow-up planning.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  5. 5

    Continue commissioning the 24-hour Clinical Assessment Service and refine its clinical advice and ambulance-call revalidation functions.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  6. 6

    Develop Urgent Treatment Centres as an alternative to Emergency Department attendance where clinically appropriate.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  7. 7

    Formalise urgent and emergency care governance through the UEC Board to lead and oversee system transformation workstreams.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  8. 8

    Develop an urgent community response service as an alternative to ambulance response or Emergency Department attendance.

    Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  9. 9

    Implement a tiered performance and improvement approach with targeted and universal support for health systems.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  10. 10

    Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Place senior clinical staff in the three acute hospitals for focused operational support, oversight and assurance during escalations.

Verbatim wording from the response

“The ICB has also placed senior clinical staff in to our three Acute Hospitals for focussed periods of on-site support, to support the management of escalations in a timely manner. Not only does this provide additional operational support to frontline colleagues, utilising ICB staff experience, it also improves ICB oversight and assurance, enabling the ICB to actively reflect on the operational impact that their system-level interventions (as described above) are having on patients and the staff delivering their care. The Norfolk and Waveney ‘Leading for System Change’ project launched in 2022, bringing together key colleagues involved in discharge across the Integrated Care System (ICS) with a focussed remit to understand, mitigate and rectify some of our underlying problems as a system which include:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Coordinate regional system-level learning through the urgent and emergency care serious-incident tactical group and feed recommendations into improvement plans.

Verbatim wording from the response

“NHS Norfolk and Waveney ICB continue to work closely with NHS Suffolk and North East Essex ICB, which is the regional lead commissioning body for the East of England Ambulance Service Trust (EEAST) to ensure there is a common approach between healthcare providers and the local ambulance service to learning and preventing future adverse incidents, including those arising from ambulance handover delays, across the EEAST footprint and the Hospitals across the region so that there is parity and consistency.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 6 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish the virtual Open Room as a substantive service to divert suitable 999 callers to alternative community pathways.

Verbatim wording from the response

“Additionally, the ICB has worked closely with our integrated urgent care provider to implement a virtual ‘Open Room’, which started as a trial in April 2022, to enable senior clinical staff in the community to ‘pull’ appropriate patients out of the 999-call queue and divert them to more appropriate alternative pathways to meet their needs. This could include interventions and services such as therapy assessments, urgent community support, medication review and community falls response. This became a substantive service from August 2022 following positive evaluation by the ICB.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue commissioning the Mental Health Joint Response Car to provide home-based mental-health triage and follow-up planning.

Verbatim wording from the response

“The ICB continues to commission the East of England Ambulance Service Trust to provide the Norfolk and Waveney Mental Health Joint Response Car (MHJRC) which enables a paramedic and mental health practitioner to triage people within their home environment, and plan follow up care, instead of an ambulance conveyance to hospital for the purposes of accessing mental health care provision, where safe and appropriate.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue commissioning the 24-hour Clinical Assessment Service and refine its clinical advice and ambulance-call revalidation functions.

Verbatim wording from the response

“The ICB continues to commission our integrated urgent care provider to deliver a 24-hour Clinical Assessment Service (CAS) run by GPs and Advanced Practitioners. The CAS undertakes revalidation of 999 calls for EEAST to help avoid unnecessary ambulance conveyances as well as delivering a direct Healthcare Professional Advice line which provides senior clinical advice, including ‘Call Before You Convey’ decision-making support for ambulance staff while they are on-scene. This work has been developing over time, with the ICB supporting a review and refinement of these services to meet presenting pressures e.g., reduction of the Healthcare Professional Advice line response standard from 30min to 10min.”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop Urgent Treatment Centres as an alternative to Emergency Department attendance where clinically appropriate.

Verbatim wording from the response

“Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Formalise urgent and emergency care governance through the UEC Board to lead and oversee system transformation workstreams.

Verbatim wording from the response

“Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop an urgent community response service as an alternative to ambulance response or Emergency Department attendance.

Verbatim wording from the response

“Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:”

Source location

Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a tiered performance and improvement approach with targeted and universal support for health systems.

Verbatim wording from the response

“We recognise there is variation in performance across the country. That is why the delivery plan also provides for a new tiering performance and improvement approach to provide targeted support to challenged systems. There is support in place at national and regional level to support Tiers 1 and 2 with a universal improvement support offer being made available for all systems which will help improve system performance across the whole patient pathway.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.

Verbatim wording from the response

“I recognise the significant pressure the NHS has been under since the pandemic. That is why we published our Delivery Plan for Recovering Urgent and Emergency Care Services. The plan aims to deliver one of the fastest and longest sustained improvements in emergency care waiting times in the NHS's history. It sets out an ambition to improve A&E wait times to 76% of patients being admitted, transferred, or discharged within four hours and to reduce average Category 2 response times to 30 minutes this year, with further improvements to be set as part of the NHS planning guidance for next year 2024-25.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026