Frederick Pring

Ymddiriedolaeth GIG
Galw [[xei0@2) Cymru Gwasanaethau Ambiwlans Cymru

MEH Direct Wales Welsh Ambulance Services NHS Trust

Pencadlys yr Ymddiriedolaeth, Safle H M Stanley, Llanelwy, Sir Ddinbych LL17 ORS
Trust Headquarters, H M Stanley Site, St Asaph, Denbighshire LL17 ORS
Tel/Ff6n 01745 532900 Fax/Ffacs 01745 532901

www.ambulance.wales.nhs.uk

Please reply to: Rose Cook
Our Ref: EPM/rc/2558 PA to the Chairman & Chief Executive
Your Ref: Direct Line: 01745 532944

19 March 2014

Mr John A Gittins

HM Senior Coroner for North Wales (East and Central)
HM Coroner's Office

County Hall

Wynnstay Road

Ruthin

LL15 1YN

Dear Mr Gittins

Re: Report for the prevention of future Deaths
Inquest of Frederick Douglas Pring

We are writing in response to your Report pursuant to Regulation 28 of the Coroners
(Investigations) Regulations 2013, dated 21 January 2014. We would like to confirm the actions
taken by the Welsh Ambulance Services NHS Trust (WAST) and Betsi Cadwaladr University
Health Board (the Health Board) in accordance with your Report.

The actions being taken by the Trust and the Health Board in relation to the three points you have
raised within the Regulation 28 notification are listed below: -

1. That the categorisation of calls and the prioritising of the allocation of resources does
not currently appear to take into account the issue of delay and the potentially
catastrophic impact of delay on both the patient and those seeking to care for him or her
without medical assistance.

The WAST utilises the Medical Priority Dispatch computer based prioritisation System (‘MPDS’)
to prioritise responses to emergency 999 calls. MPDS has been developed over the past 30
years, and provides a consistent and precise, evidence based approach to prioritising each 999
call. It is a system that is most widely used by UK ambulance services.

Response to John Gittins, HM Senior Coroner

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This system is regulated by the International Academy of Emergency Dispatch (IAED), who
provide an overarching and robust clinical governance structure by which MPDS operates, is
governed and remains credible. These international standards of prioritising emergency calls
provide WAST with the capability to safeguard its quality of patient care, by sending the
appropriate emergency medical services (EMS) response to 999 calls.

MPDS operates by having thirty three call handling protocols, which are designed to identify a
prioritisation code (ranging from ‘ECHO’ codes - immediately life threatening situations requiring
Advanced Life Support by EMS; to OMEGA codes - calls that can be referred to other health
and social care providers). Based upon the prioritisation code, which is set by the IAED, each

service using MPDS has to stipulate the type, number and mode (i.e. with blue lights or non blue
lights) of response to incidents.

As per the recommendations of the IAED, ratification of the type of response (based upon the
MPDS code) remains the responsibility of the individual Trust's Medical Director. Historically,
WAST has adopted the same responses to MPDS codes that were set by the Department of
Health (DoH) for other UK Ambulance Services. The only amendment to this has been that
WAST has reserved the right to ‘upgrade’ responses (i.e. use of blue lights), but never
‘downgrade’ responses. In addition, where it becomes evident that a patient's condition has
deteriorated following further contact with a caller, the call taker reprioritises symptoms utilising
MPDS, resulting in the allocation of a higher tier of response. The call taker will also provide
further telephone advice (e.g. on how to perform chest compressions in a cardiac arrest) until
such time that an ambulance arrives at the incident.

As a result of Welsh Government issuing new National Ambulance Performance Standards
(December 2011) WAST introduced its Clinical Response Model. This model aims to focus on
providing a timely and clinically appropriate response to patients. It maximises resource
availability to respond to the most seriously ill/injured patient. This is achieved by utilising a
response configuration which is closely aligned to the fundamental principles of the National
Academy of Emergency Medical Dispatch and the use of the MPDS system.

The standards require that the categorisation of 999 calls is based upon two definitions:-

¢ Immediately life threatening (Red 1 & 2 responses; 8 minutes)

e Either serious but not life threatening or neither serious nor life threatening (Category C: Green
1, 2 & 3 responses; 30 minutes) The Welsh Ambulance Service's Response Model unlike our
English counterparts combines Green 1 and 2 as a face to face 30 minute response.

The Clinical Response Model, which drives resource allocation, recognises that at times
demand can outstrip available resource and sometimes there are no resources available to
send to more life threatening calls. The response model in these circumstances specifies that if
the closest resource is already mobile to a lower acuity call, it must be stood down by an
allocator and diverted to the more serious life threatening calls. If the closest resource is already

on the scene of a lower acuity call the crew must be contacted and asked if they are able to
attend a more serious call.

Response to John Gittins, HM Senior Coroner

Once calls are prioritised by the Emergency Medical Dispatch (EMD) call taker the calls are
placed on a stack and allocated in order of acuity and time received. Where there is a delay in
sending ambulance resources EMD call takers are trained to support the caller and provide
telephone instructions until trained help arrives. This can only be effective if there is no
prolonged delay in response.

Other measures in place when demand outstrips available resources are cross boundary
support from other ambulance localities in Wales and cross border ambulances services in
England.

The Trust recognises that these measures, whilst maximising available resources, do not take
into account delays in allocating a response. Bench marking with other United Kingdom
Ambulance Trusts has identified that their clinical response models have been adapted since
2012, to provide a broader scope of categorisations and thus greater flexibility in identifying and
responding to higher acuity incidents.

WAST will review the Welsh MPDS codes and accompanying response recommendations
(known as the ‘DCR’ table), with the intention of broadening the current response categories
listed above to further distinguish between higher and lower acuity calls. The Trust will identify
MPDS codes that are definitely serious, not life threatening but requiring urgent on-scene
assessment, treatment and conveyance, with the intention of decreasing the Green 1 response
time for these incidents from 30 to 20 minutes. This will provide an opportunity to declassify
some current Red 2 responses to Green 1. Additionally, the Trust will review the determinant
codes currently receiving a Green 1 response, with the intention of moving them, where clinically
appropriate, within the dispatch table to Green 2 status providing either a 30 minute response or
immediate telephone assessment where it is deemed clinically appropriate.

In line with our Clinical Transformation strategy, Clinical Hubs will be established in our Clinical
Contact Centres comprising multidisciplinary teams in order that secondary clinical triage can be
undertaken to augment the AMPDS system. In line with the strategy, we have already
introduced Advanced Paramedic Practitioners in the Clinical Contact Centres to support patient
safety and reduce any potential clinical risk

These measures will more clearly identify life threatening incidents, highlighting their priority for
dispatch during periods of resource delays. Further detail describing this key development
more fully can be provided if helpful to the Coroner. The Trust will undertake to keep the
Coroner updated periodically on the implementation of its Clinical Hubs.

2. That the Rest Break Policy generally, but particularly in relation to the standing down of
the crews whilst returning to base for mandatory breaks, may result in an unacceptable
diminution in available resources and to this end | would positively encourage a greater
degree of sharing of NHS facilities between Health Board staff and Ambulance staff so as
to minimise where possible, the need to return to base.

The Trust Board has resolved that, in future, workforce policies must be constructed from an
objective point of view, must be defensible and stand up to public scrutiny. Whilst there must be

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Response to John Gittins, HM Senior Coroner

the right balance between staff welfare and patient safety, ultimately, the Trust must be able to
effectively manage the resources available to it, taking into account clinical demands on the
service, patient and staff safety and dynamically risk assessing this in real time. A series of
workplace policies are due to be presented to the Trust Board (beginning in March 2014) to be
ratified so that changes in practice such as those described below can be implemented.

At the time of the incident the practice was for crews who were travelling back to their base for
their break not to be interrupted if they were beyond 5-6 hours from start of their shift.

The Trust is reviewing its meal break policy with the aim that staff in the future will take their
break at the most appropriate place. Whilst there is more work to be done this important policy
is being discussed further by the Trust Board on 20 March 2014. The Trust recognises that the
implementation of this policy is needed urgently.

All the Heads of Service in the Trust have made arrangements with the respective Health
Boards for staff to have their main breaks in the Hospitals and other NHS facilities and staff who
work more than 10 hours are also able to take their supplementary breaks at those NHS
facilities, rather than return to their base.

We are having discussions with Health Trusts in England to enable the same arrangements for
staff to take breaks when they taking patients to hospitals in England.

The Trust has a Voluntary Availability and Disturbance Procedure (this was developed in 2008
as an addition to the Rest Break Policy) which operates in conjunction with the current Rest
Break Policy and recognises the problems associated with providing cover for crews on their

main, unpaid rest break and that some employees wish to make themselves available for calls
during this unpaid break.

In this respect there are now increased opportunities for the Voluntary Availability and
Disturbance Policy to be applied by Clinical Contact Centres (CCCs) to request staff to be
available during their rest breaks in emergency circumstances, which is not call specific.

Crews are disturbed during their paid supplementary break for an emergency Red Call
categorised as a Red 1 and Red 2. If the crew is disturbed during the first 15 minutes of their 30
minute supplementary rest break window they will be allocated a further 15 minutes at the
completion of their shift. There will be no recompense in time for any disturbance in the last 15
minutes of the period.

The Trust has adopted an education programme for the control staff to promote the new policy
and to ensure there is a consistent approach in application across the Trust. This will be
implemented when the new policy is formally approved.

The BCU Health Board actively supports WAST crews to utilise its facilities in support of
mandatory breaks. Details of facilities and availability in BCU are included within Appendix 1.

Response to John Gittins, HM Senior Coroner

3. That the current practices in place for the handover of patients at an Emergency
Department far too often result in wholly unacceptable delays with patients being kept
waiting for long periods in ambulances and ambulance resources consequently being
unavailable for allocation to other calls. Whilst this is a multi-factorial problem,
improvements must be made so as to reduce the risk of future deaths.

We would like to take this opportunity to provide you with assurance that the Health Board and
the Trust are committed to ensuring handover processes are in place that are safe and effective;
and when there are circumstances of patients experiencing delays during handover steps are
taken to ensure patients are properly monitored and that any changes in their condition are
communicated and acted upon appropriately.

The Health Board is taking all reasonable steps to improve “patient flow” within each community
area and District General Hospital. Many of the pressures experienced in Emergency
Departments (and by the Welsh Ambulance Service) are due to capacity within the community
to respond to urgent clinical problems before they become emergencies, and also maintaining
an adequate flow of patients through and out of the hospital system so our Emergency
Departments do not get overcrowded.

The issues which you have raised are vitally important and the Health Board is committed to
working with the Ambulance Trust and other partners to improve the current situation as a
matter of urgency. The BCUHB Medical Director has communicated these issues to all Clinical
Leaders, Consultant Medical Staff and NHS Professional Managers across the Health Board.
(Please see Appendices 2 & 3)

A ‘Delivery Group’ has been commissioned by the Local Health Board comprising of Senior
Managers from the two organisations to oversee developments within Unscheduled Care in
North Wales. The Group has various work streams to implement approaches which will improve
flow and signpost patients to alternative pathways of care, as opposed to conveying to
Emergency Departments by default. In line with the practice in the other Clinical Contact
Centres, Advanced Paramedic Practitioners (APPs) are now working within the Clinical Contact
Centres in order to enhance patient safety and to provide clinical advice to control based and
operational WAST colleagues, and also to patients and relatives who require our services. The
Group is considering extending the Consultant currently seconded in the North Clinical Contact
Centre and also exploring the possibly of enhancing the facility through utilising extended hours.
Specific ongoing work includes: -

* Redefining ‘border’ areas to equate the volume of WAST attendances at the three DGHs;

¢ Llandudno Hospital Minor Injuries (MIU) access criteria have been amended to allow more
patients to be treated in this site as opposed to utilising Glan Clwyd or Ysbyty Gwynedd ED;

* The role of Llandudno MIU is being strengthened with 2 WAST Trainee Advances
Practitioners receiving mentorship from a BCU Consultant based in Llandudno MIU and will
work one shift per week at the MIU but will be available to respond to any calls in the area;

« WAST and the Health Board are conducting more joint training for Silver “On Call
managers from both organisations;

Response to John Gittins, HM Senior Coroner

Serious Adverse Incident Reviews will be conducted jointly if there are issues relative to
both organisations;

There are early discussions considering the feasibility and benefits for a North Wales Bed
Bureau.

Since receiving your letter the Health Board has communicated the issues to the operational
and clinical teams and worked with those clinical teams to improve the situation concerning
delays in ED admission and the knock on impact on ambulance resources. The Health Board’s
Medical Director has worked with the appropriate Chiefs of Staff and Departmental Heads
aiming to improve patient flow and improved patient discharge arrangements (Please see
Appendices 2 & 3). There has been communication with all senior medical staff to outline their
roles and responsibilities in improving patient care with respect to ED review, admission and
discharge. Meanwhile specific initiatives have been planned for implementation within the next
1-2 months.

(1)

(3

pu

(4)

There will be monthly clinical audits performed to provide assurance regarding the safe
management of patients who are delayed in Ambulances outside Emergency Departments
prior to admission. The audits will facilitate the implementation of practice changes which
improve patient flow. The results of the audit will be presented to the Medical Director,
Director of Nursing, Interim Chief Operating Officer, local Hospital Management Teams,
local Patient Safety Groups to ensure Health Board assurance. The audit tool is attached
(Please see Appendix 4).

WAST and the Health Board have accelerated the discussion which was taking place
relating to agreement and implementation of a “flow chart’ (Please see Appendix 5 (in
draft)) to address the clinical risks relating to patients waiting in Ambulances. This is being
further discussed at a meeting on Thursday 27 March 2014.

There will be a focus on implementing the “Frailty Programme” to provide early supportive
discharge across the Health Board. The Health Board has two teams taking part in the
National Patient Flow Collaborative which has clear aims to make consistent and
sustainable improvements to Unscheduled Care.

WAST and the Health Board are working together with colleagues across Wales regarding
completion of an All Wales Handover Policy which describes evidence based processes for
patient handover between clinical teams. We will forward this to you as soon as it is
completed and agreed.

The Health Board attended the Royal College of Physicians (RCP) and proposed that it acts
as a “Demonstrator Site” to implement the RCPs “Future Hospitals Commission Report” that
referred to many of the issues that result in overcrowding in Emergency Departments.

In conclusion

We hope that this joint response from WAST and the Health Board provides you with the
assurances you require in response to the content of your Regulation 28 letter dated 21 January

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Response to John Gittins, HM Senior Coroner

2014. Both organisations are committed to learn lessons from this difficult case and ensure that
patient outcomes are improved with more effective clinical care without delays. The necessary
improvements and changes are varied and cut across WAST and the Health Board’s
responsibilities as well as other organisations in North Wales. They are being implemented as
quickly as possible and WAST and the Health Board will continue to monitor these actions as a
part of their assurance/performance management arrangements including Board level review.

Please contact us if any of this report of progress to date is unclear or if there are still areas of
concern. We commit to keep you informed of progress with respect to the key initiatives occurring
in North Wales as well as those with an all Wales impact. Thank you once again for your letter
regarding these very important issues.

Yours sincerely

Elwyn Price-Morris Matthew K Makin

Prif Weithredwr Cyfarwyddwr Meddygol a Gwasanaethau
Ymddiriedolaeth GIG Gwasanaethau Clinigol

Ambiwlans Cymru Bwrdd lechyd Prifysgol Betsi Cadwaladr
Chief Executive Medical Director and Director of Clinical
Welsh Ambulance Services NHS Trust Services

Betsi Cadwaladr University Health Board

Response to John Gittins, HM Senior Coroner