PFD report

Sophie HINDMARSH · Prevention of Future Deaths report

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Issued 29 Apr 2024•South Yorkshire (Western)

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
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. Delays in offloading ambulance patients at hospitals
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
  2. Failure to provide ambulance responses within the required 40 minutes
    Part of recurring concern: Delays in ambulance attendance
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.8

  1. Action

    Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  2. Action

    Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from A&E.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  3. Action

    Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Specific actions to improve ambulance response and hospital handover times will be provided directly by NHS England and the Integrated Care Board.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Delays in offloading ambulance patients at hospitals

Wider context from the report

“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls. ”

Is this part of a recurring concern?

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

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 provide ambulance responses within the required 40 minutes

Wider context from the report

“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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

Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.

Verbatim wording from the response

“Your report highlights that YAS were under high demand at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.”

Source location

Response from DHSC
Page 1 · response
Published 9 May 2024

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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

Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from A&E.

Verbatim wording from the response

“£1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.”

Source location

Response from DHSC
Page 2 · response
Published 9 May 2024

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 £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.

Verbatim wording from the response

“Your report highlights that YAS were under high demand at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.”

Source location

Response from DHSC
Page 1 · response
Published 9 May 2024

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

Introduce and enact a Duty to Rescue protocol enabling senior clinical decisions on rapid handover and ambulance release during significant operational pressure.

Verbatim wording from the response

“Implementation of Duty to Rescue protocol - this protocol was introduced ahead of the winter period (2023/24) and is now enacted at times of significant operational pressure. On occasions when there are high number of ambulances waiting to handover patients, the protocol allows for senior clinical decision makers from YAS and our hospitals to agree to the rapid handover and timely release of an ambulance crew to attend to a specific 999 call, or one who has been awaiting conveyance and is deteriorating. The introduction of this protocol has been welcomed by all parties and allows for clinical risks to be better managed in the system.”

Source location

Response from West Yorkshire ICB
Page 3 · response
Published 9 May 2024

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 and use a Joint Escalation Action Plan defining organisational actions to improve ambulance handover during system pressures.

Verbatim wording from the response

“YAS and Sheffield Teaching Hospitals (including other South Yorkshire Hospitals) have agreed a new Joint Escalation Action Plan (JEAP), for when system pressures increase. This plan provides specific actions that organisations must employ to support the improvement of ambulance handover.”

Source location

Response from West Yorkshire ICB
Page 3 · response
Published 9 May 2024

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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

Develop and improve alternative care pathways, including Urgent Community Response and direct Same Day Emergency Care access, to avoid appropriate hospital conveyance.

Verbatim wording from the response

“Alternatives to Accident and Emergency (A&E) Departments – more alternative pathways of care are available for use by YAS Ambulance crews or staff within the Emergency Operations Centre (EOC) to safely and appropriately avoid conveyance to hospital.”

Source location

Response from West Yorkshire ICB
Page 3 · response
Published 9 May 2024

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 quality-improvement initiatives with acute trusts to reduce ambulance handover delays.

Verbatim wording from the response

“The correlation between handover delays at Emergency Departments and overall ambulance response times is widely acknowledged. Handover times vary amongst our acute trusts in the region. We seek to ensure the root causes are understood.”

Source location

Response from West Yorkshire ICB
Page 3 · response
Published 9 May 2024

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 to improve ambulance and urgent-care performance.

Verbatim wording from the response

“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.”

Source location

Response from NHS England
Page 1 · response
Published 9 May 2024

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

Specific actions to improve ambulance response and hospital handover times will be provided directly by NHS England and the Integrated Care Board.

Verbatim wording from the response

“Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.”

Source location

Response from DHSC
Page 1 · response
Published 9 May 2024

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.7

  1. 1

    Discuss the Regulation 28 concerns through the YAS Clinical Quality Oversight Group and share them with senior regional clinical leaders.

    Stated by NHS West Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  2. 2

    Share the Regulation 28 report and concerns through the South Yorkshire Urgent and Emergency Care Alliance Board.

    Stated by NHS West Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  3. 3

    Provide clinical navigators and employed GPs within the Emergency Operations Centre to support remote assessment, clinical decision-making and appropriate care direction.

    Stated by NHS West Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  4. 4

    Develop a System Coordination Centre to coordinate providers across the ICB footprint and support proactive responses to operational pressures and risks.

    Stated by NHS West Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  5. 5

    Continue improving Emergency Operations Centre referral processes to divert demand appropriately into alternative care pathways.

    Stated by NHS West Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  6. 6

    Operate the Regulation 28 Working Group to discuss reports and share learning about preventable deaths across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  7. 7

    Grow, train, retain and reform the NHS workforce, including expanding urgent and acute care medical specialty training.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.

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 the Regulation 28 concerns through the YAS Clinical Quality Oversight Group and share them with senior regional clinical leaders.

Verbatim wording from the response

“This Regulation 28 has been discussed at the YAS Clinical Quality Oversight Group with senior clinical leaders of the constituent organisations to share the matters of concern raised across the Yorkshire and Humber region. This reports to the ELB which has oversight of the Ambulance Service in Yorkshire. Within South Yorkshire, this Regulation 28 report and matters of concern will be shared through the Urgent and Emergency Care Alliance Board made up of senior leaders from all of the constituent bodies.”

Source location

Response from West Yorkshire ICB
Page 4 · response
Published 9 May 2024

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

Share the Regulation 28 report and concerns through the South Yorkshire Urgent and Emergency Care Alliance Board.

Verbatim wording from the response

“This Regulation 28 has been discussed at the YAS Clinical Quality Oversight Group with senior clinical leaders of the constituent organisations to share the matters of concern raised across the Yorkshire and Humber region. This reports to the ELB which has oversight of the Ambulance Service in Yorkshire. Within South Yorkshire, this Regulation 28 report and matters of concern will be shared through the Urgent and Emergency Care Alliance Board made up of senior leaders from all of the constituent bodies.”

Source location

Response from West Yorkshire ICB
Page 4 · response
Published 9 May 2024

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 clinical navigators and employed GPs within the Emergency Operations Centre to support remote assessment, clinical decision-making and appropriate care direction.

Verbatim wording from the response

“The EOC have continued to invest in the clinical workforce using clinical navigators to assist in the identification of incidents suitable for an alternative response or which can be clinically assessed and given self-care advice. General Practitioners (GPs) have also been employed to both assist with remote assessment and also to support clinical decision making more generally to improve outcomes and ensure patients are directed to appropriate care relevant to their needs.”

Source location

Response from West Yorkshire ICB
Page 4 · response
Published 9 May 2024

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 System Coordination Centre to coordinate providers across the ICB footprint and support proactive responses to operational pressures and risks.

Verbatim wording from the response

“The EOC continues to improve their referral processes to other services therefore appropriately diverting demand into alternative care pathways. A System Coordination Centre (SCC) has also been developed over the past year. The SCC exists to be a central co-ordination service to providers of care across the ICB footprint to enable a proactive system response to operational pressures and risks with the aim to support patient access to the safest and best quality of care possible.”

Source location

Response from West Yorkshire ICB
Page 4 · response
Published 9 May 2024

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 improving Emergency Operations Centre referral processes to divert demand appropriately into alternative care pathways.

Verbatim wording from the response

“The EOC continues to improve their referral processes to other services therefore appropriately diverting demand into alternative care pathways. A System Coordination Centre (SCC) has also been developed over the past year. The SCC exists to be a central co-ordination service to providers of care across the ICB footprint to enable a proactive system response to operational pressures and risks with the aim to support patient access to the safest and best quality of care possible.”

Source location

Response from West Yorkshire ICB
Page 4 · response
Published 9 May 2024

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

Operate the Regulation 28 Working Group to discuss reports and share learning about preventable deaths across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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

Grow, train, retain and reform the NHS workforce, including expanding urgent and acute care medical specialty training.

Verbatim wording from the response

“In June 2023, NHS England published the NHS Long Term Workforce Plan, which sets out how we will grow, train, retain and reform the NHS workforce over the next fifteen years to help meet the growing demands on our services. It is underpinned by the biggest recruitment drive in NHS history and includes an expansion of medical specialty training for urgent and acute care.”

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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