PFD report

Diana FAIRWEATHER-PURKIS · Prevention of Future Deaths report

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Issued 17 Feb 2025•Teesside and Hartlepool

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.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
15

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 raised2

  1. Insufficient ambulance service availability or resources for timely patient attendance
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
  2. Delays in ambulance crew release following hospital attendance
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
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.11

  1. Action

    Prioritise improvements to Category 2 ambulance response times and urgent and emergency care services.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
  2. Action

    Work with commissioners, integrated care boards, acute providers and ambulance services to implement plans improving ambulance handovers.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
  3. Action

    Provide over £40 million in additional ambulance-service funding to increase vehicles on the road and strengthen clinical advisory services.

    Stated by NHS North East and North Cumbria Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.

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 ambulance service availability or resources for timely patient attendance

Wider context from the report

“1. There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Insufficient ambulance service capacity for emergency calls.

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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 ambulance crew release following hospital attendance

Wider context from the report

“2. There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover.

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

Prioritise improvements to Category 2 ambulance response times and urgent and emergency care services.

Verbatim wording from the response

“NHS England recognises the significant pressures on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. Improvements to Category 2 response times will have a positive impact across ambulance performance generally, including Category 3 responses.”

Source location

Response from NHSE
Page 1 · response
Published 20 February 2025

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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

Work with commissioners, integrated care boards, acute providers and ambulance services to implement plans improving ambulance handovers.

Verbatim wording from the response

“NHS England’s regional teams are continuing to work closely with commissioners, Integrated Care Boards (ICBs), acute NHS providers and ambulance services to implement plans to continue to improve patient handovers. The 2025/26 priorities and operational planning guidance sets out that the NHS should improve ambulance response times and Accident and Emergency (A&E) waiting times compared to 2024/25, and that Category 2 ambulance response times should average no more than 30 minutes across 2025/26. The guidance also sets out some immediate tasks for 2025/26, including to reduce avoidable ambulance dispatches and conveyances and reduce handover delays.”

Source location

Response from NHSE
Page 2 · response
Published 20 February 2025

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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 over £40 million in additional ambulance-service funding to increase vehicles on the road and strengthen clinical advisory services.

Verbatim wording from the response

“Since the creation of the North East and North Cumbria Integrated Care Board (NENC ICB) in July 2022 there has been significant investment of additional resources into ambulances services to increase capacity and availability. Over £40m of additional funding, made up of local ICB investment and a share of nationally funded NHS England growth monies, has been made available to the North East Ambulance Service (NEAS) since 2023/24 to increase the number of vehicles on the road and also strengthen clinical advisory services.”

Source location

Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Page 1 · response
Published 20 February 2025

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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 an integrated urgent-care clinical assessment service providing multidisciplinary telephone triage and onward referral support for 111 and 999 callers.

Verbatim wording from the response

“NEAS have established an Integrated Urgent Care Clinical Assessment Service (IUCAS) which includes paramedics, nurses, advanced practitioners, pharmacists, GPs and clinical specialists who provide enhanced clinical support to call handlers and patients ringing 111 and 999. Senior clinical advisors (clinicians) provide additional clinical assessment via telephone triage, improving the journey and experience for our patients by ensuring they can pass through to services quickly and efficiently. The team also promotes self-care, provides advice and support for patients at home, facilitating onward referral where necessary to a range of primary and secondary care services. By being able to increase the number of patients who are treated and discharged in the community, the IUCAS helps to reduce pressures on ambulances, emergency departments, and other NHS services.”

Source location

Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Page 1 · response
Published 20 February 2025

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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 multi-agency ambulance-handover improvement and transformation work across the integrated care system.

Verbatim wording from the response

“Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).”

Source location

Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Page 2 · response
Published 20 February 2025

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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 implementing system-wide improvement programmes with ambulance and acute hospital providers to improve ambulance response times during 2025/26.

Verbatim wording from the response

“With regard to ambulance performance and the target response times, NEAS are consistently the highest performing ambulance provider in England across all 4 response time categories and continue to implement system-wide improvement programmes in conjunction with ICB and our acute hospital providers to further improve response times throughout 2025/26 and work towards achieving the NHS constitutional standards.”

Source location

Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Page 2 · response
Published 20 February 2025

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

Agree revised and standardised policies and procedures for ambulance handover processes, including immediate release, cohorting, diversions and deflections.

Verbatim wording from the response

“Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).”

Source location

Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Page 2 · response
Published 20 February 2025

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 2025 mandate to NHS England prioritising improved A&E and ambulance waiting times.

Verbatim wording from the response

“On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.”

Source location

Response from DHSC
Page 2 · response
Published 20 February 2025

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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 NHS planning guidance requiring action to improve Category 2 ambulance response times and reduce avoidable dispatches, conveyances and handover delays.

Verbatim wording from the response

“On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.”

Source location

Response from DHSC
Page 2 · response
Published 20 February 2025

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 lessons learned from winter urgent and emergency care pressures.

Verbatim wording from the response

“In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

Source location

Response from DHSC
Page 2 · response
Published 20 February 2025

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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

Put in place improvements to urgent and emergency care services ahead of the next winter.

Verbatim wording from the response

“In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

Source location

Response from DHSC
Page 2 · response
Published 20 February 2025

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.4

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.
  2. 2

    Publish the 10-Year Health Plan setting out reforms to move care into communities, expand digital approaches and strengthen prevention.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
  3. 3

    Provide additional NHS revenue and capital investment to increase appointments and reduce waiting times.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.
  4. 4

    Publish the Plan for Change setting national reform milestones, including development of an NHS fit for the future.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.

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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

Verbatim wording from the response

“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 Diana, 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.”

Source location

Response from NHSE
Page 3 · response
Published 20 February 2025

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 10-Year Health Plan setting out reforms to move care into communities, expand digital approaches and strengthen prevention.

Verbatim wording from the response

“In Spring 2025, to accompany the additional investment in the NHS, the Government will publish its 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future.”

Source location

Response from DHSC
Page 2 · response
Published 20 February 2025

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 NHS revenue and capital investment to increase appointments and reduce waiting times.

Verbatim wording from the response

“To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010.”

Source location

Response from DHSC
Page 1 · response
Published 20 February 2025

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 Plan for Change setting national reform milestones, including development of an NHS fit for the future.

Verbatim wording from the response

“We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future.”

Source location

Response from DHSC
Page 1 · response
Published 20 February 2025

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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