Mandeep Singh

North East Ambulance Service INHS

NHS Foundation Trust
fork:

Ambulance Headquarters.

Private and Confidential Bernicia House

The Waterfront
Claire Bailey 0 Goldcrest Way
Acting Senior Coroner 3 M4 y Newburn Riverside
Her Majesty's Coroner for Teesside Og Newcastle upon Tyne

The Coroner's Service NE15 8NY

Middlesbrough Town Hall :

Tel: 0191 430 2000
Albert Road www.neas.nhs.uk
Middlesbrough

TS1 2QJ rot

27" April 2016

Dear Ms Bailey
Inquest into the death of Mandeep Singh

Regulation 28: Report to Prevent Future Deaths

We are writing further to your letter of 23 March 2016 enclosing a Regulation 28 report to prevent
future deaths which you issued following the Inquest into the death of Madeep Singh which was held
on 18 March 2016.

The matters of concern highlighted in your report are:

“A root cause analysis comprehensive and independent investigation report undertaken by the North
East Ambulance Service discloses that the reason for the delay of the ambulance arrival include
severe demand and shortages in the division. Road closures and diversions did not assist the
crews."

North East Ambulance Service NHS Foundation Trust ("the Trust") is disappointed to have received a
Regulation 28 report having not been called to provide evidence at the Inquest. At the Inquest the
Trust would have been able to provide details of the current issues affecting the Trust in relation to
staff shortages and to provide updates of the numerous steps which the Trust are taking to increase
ambulance and paramedic resources in an attempt to alleviate, as far as is reasonably practicable,
delays in Trust services attending on patients calling the Trust for assistance. We will address each
point you have raised in your matters of concern below:

Severe demand

The Trust is limited in ways in which it can control the calls made to it and the demand on its services.
However, the Trust has undertaken initiatives to seek to educate both the public in relation to the
appropriateness of making calls and to work with colleagues in other sectors to try to reduce the
demand on Trust services.

In relation to members of the public the Trust has done extensive advertising including placing signs
on the side of its vehicles highlighting whether calls to the ambulance services are really necessary or
whether other agencies could assist.

Chairman: Ashley Winter | Chief Executive: Yvonne Ormston
The North East Ambulance Service NHS Foundation Trust is registered, and therefore licensed to provide services, by the Care Quality Commission (Provider ID; RX601)

The Trust has also carried out demand reduction work locking at how to reduce the number of red
calls made by looking at the appropriateness of those red calls.

The Trust has worked with colleagues in relation to demand reduction. The Trust has worked with
health colleagues for example GP's, to ascertain whether requests for ambulance transfers can be
reduced.

The Trust has also worked with the police to see if any reduction in ambulances requested by the
police can be effected.

In January 2016, the Trust commenced a new six-month trial scheme with the four Fire and Rescue
Services based in the region. This includes Cleveland Fire Brigade, County Durham and Darlington
Fire and Rescue Service, Northumberland Fire and Rescue Service and Tyne and Wear Fire and
Rescue Service.

During this innovative trial, an Emergency Medical Responder (EMR) will be dispatched at the same
time as an ambulance. The Trusts ambition for this trial is to improve the survival rate for those people
who suffer from a life-threatening illness or injury in the community. The location of EMR's within local
communities could mean they are nearer to the scene and can deliver lifesaving care in those first
critical minutes of the emergency until an ambulance clinician arrives, enhancing the usual
emergency medical response from NEAS.

During the trial, Emergency Medical Response Units, in the form of fire appliances, will deliver
emergency medical services when requested by NEAS. The emergency medical services included
may involve attending calls where people are suffering from chest pain, difficulty in breathing, cardiac
arrest and unconsciousness not due to trauma.

Emergency Medical Responders have been trained to enhance their existing medical care
knowledge, including basic life support by managing a patient's airway, giving oxygen therapy,
including assisted ventilation, delivering cardio-pulmonary resuscitation (CPR) and defibrillation using
a semi-automatic AED and controlling blood loss.

The EMR's are equipped with a kit which includes oxygen and an automated external defibrillator
(AED) to help patients in a medical emergency such as a heart attack, collapse or breathing
difficulties.

Finally the Trust has worked in partnership with Durham Constabulary and County Durham and
Darlington Fire and Rescue Service to introduce the region’s first tri-responders working for police, fire
and ambulance. The Community First Responders work for Durham Constabulary as PCSOs, County
Durham and Darlington Fire and Rescue Service as retained firefighters and as first responders for
the NEAS.

It is believed to be only the second project of its kind in the country and was part funded through the
national Police Innovation Fund.

The scheme is designed to increase collaboration between the three services and allow efficiencies
without reducing frontline services.

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Shortages in the division
Background

By way of background, there remains a shortage of individuals entering the paramedic profession.
This has been the case for some time and is a national issue, which is not exclusive to the North East
of England. However, this issue was particularly acute in the North East, where the turnover rate for
paramedic staff has increased progressively over the last few years due to a number of factors,
including the pressure of increased workload. In light of this, attrition rates for paramedics were high,
with more staff leaving the service, whether by way of retirement or to pursue alternative career paths,
than the number of staff who could be recruited to fill those vacancies. The Migration Advisory
Committee had previously reported that there was a national shortage of individuals entering the
paramedic profession.

Managing Director of the Association of Ambulance Chief Executives has been
previously quoted in the media as stating that: “the national shortage of paramedics is affecting all
Trusts and the Association of Ambulance Chief Executives is working closely with Health Education
England to improve the situation. Ambulance Trusts are also having to think of ever more creative
ways to recruit to vacant posts“.

On a similar note, an article from the Health Service Journal, dated 20 May 2015, considered the
impact of paramedic resource attrition. This confirmed the problem with front line staff having left
ambulance trusts across the country. It indicated that the figures had almost doubled in the past 5
years and that there was evidence that emergency staff were leaving in increasing numbers. The
article specifically noted that the number of front line staff leaving ambulance services increased from
626 in 2010 - 2011 to 1,223 in 2014 - 2015. Furthermore, the article highlighted that these numbers
did not include staff who had died, reached retirement age or explicitly told their employer trusts that
they were resigning because of personal —— noted in this article that
paramedics were an: “increasingly valuable resource". further indicated that there were
now more opportunities for paramedics to pursue careers in alternate areas of the health sector, both
in the public NHS sphere and in the private sector. This included individuals who were qualified as
paramedics opting to work in Accident & Emergency Departments, Urgent Care Centres, the NHS
411 service (formerly NHS Direct) and in Government roles.

The above noted article continued by explaining that Health Education England had increased the
number of training places for paramedics by 44% in its 2015 - 2016 national workforce plan. We will
set out below the steps the Trust have taken and continue to take in order to deal with the delays in
paramedics qualifying following university education and training. Notwithstanding this, the Health
Service Journal did note that the additional commissions from Health Education England would not
produce qualified paramedics until 2016-2017, with national forecasts suggesting a potential gap
between demand and supply. In light of this, Health Education England recommended that
paramedics were placed on the Government's shortage occupational list.

Monitor publish quarterly performance reports, in respect of NHS Foundation Trusts. Monitor is the
national regulator for NHS Foundation Trusts. These reports detail ambulance response times. The
most recent report issued in February 2016 highlights that demand for ambulance services also rose.
Time critical (Category A Red 1) and life threatening (Category A Red 2) calls increased by 1.43%
and 4.7% respectively. Ambulance services failed to achieve all key response time targets against
Red 1, Red 2 and Category A calls.

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The report goes on to highlight that the national standard sets out that 7% of time critical and life
threatening Category A {i.e. Red 1 and Red 2) calls should receive an emergency response within
eight minutes, and 95% of all Category A calls should receive an emergency response within 19
minutes. For the second consecutive quarter, ambulance services failed Red 1, Red 2 and Category
A response time targets with performances of 72.61%, 67.76% and 92.71% respectively. During Q3
2015/16, only 2 of the 11 ambulance services achieved the Red 1 and Red 2 standards and three
achieved the Category A standard. NEAS was not within this group.

Ambulance services saw a rise in time critical and life threatening calls during the quarter. Circa
45,500 Red 1 calls were responded to by ambulance services, an increase of 1.43% from Q3
2014/15. The number of Red 2 calls also saw a 4.7% increase compared to the same period last
year. In total, ambulance services responded to 825,000 Red 2 calls.

The Trust's overall performance for Red calls (which is made up of both Red 1 and Red 2
dispositions) was 68.58% for 2015 - 2016, which is below the national target.

In order to seek to address this shortfall, the Trust has been following an Emergency Care Workforce
Plan. This Workforce Plan has always existed however, given the increase in attrition of staff, a Task
and Finish Group was established in October 2014, in order to ensure that the Trust is employing as
many strategies as possible to increase emergency workforce numbers. This includes a two-year
programme designed to increase the number of paramedics employed by the Trust and involves
various initiatives which are aimed at tackling the problem of paramedic attrition. We will explain in
greater detail below the specific steps which the Trust is taking pursuant to the Workforce Plan to
address resource and recruitment issues. It was previously hoped that the process to address the
current shortfall in paramedics would be fully addressed by September 2016. While the Trust has
made considerable advances in improving its paramedic resource base, it has encountered
challenges, primarily the fact that all ambulance services are seeking to recruit the same individuals.
As such, the Trust hope that with the various ongoing measures and strategies in place, this process
will be complete by around March 2017.

Before going on to explain the Workforce Plan in greater detail, it should be noted that one major
issue which has for some time been impacting on Trust ambulance resource availability, (both in the
North East and more widely across the country), and is continuing to have an adverse impact with
respect to paramedic resources arriving to treat patients in a timely fashion, is ambulances having to
queue at Accident and Emergency Departments for excessive periods of time in order to hand
patients over to hospital clinicians. As noted, this is a national issue and has been reported in both
the local and national media on a regular basis. Such delays have a major impact on the Trust's
vehicle and paramedic resources, which are available to attend to emergency calls. We therefore
also set out below details of certain measures which the Trust has been taking for some time, in
conjunction with local hospitals in the region, to attempt to address this issue.

In addition to the issues raised above, the Trust also experiences the usual resource pressures faced
by any large organisation, including absence due to sickness, maternity/paternity leave, career breaks
and secondments, as well as staff operating on only fixed term contracts. We will set out in further
detail below the steps which the Trust has been actively taking in order to address these additional
pressures, with the aim of improving paramedic resource availability and avoiding delays in
ambulances arriving to attend on patients.

A final issue which has had a major impact on ambulance resource availability is the fact that the
number of calls classified as Red (life threatening) incidents has been increasing over the last few
years. This higher Red disposition rate is also having an effect on the Trust's response times to
Green calls (30 minute — 1 hour responses), with patients waiting currently longer on average for an
ambulance than was previously the case. For instance, in 2016, the rate of red calls has increased by
16% from 2015. Such delays by their very nature are resulting in an increased number of calls to the
Trust's Contact Centre requesting an estimated time of arrival for an ambulance. This is also having a
negative impact on Contact Centre call answering performance.

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An estimated time of arrival (ETA) call is where a patient/caller has already telephoned for an
ambulance, which has been dispatched, but then places an additional call in order to ascertain when
the ambulance is likely to arrive.

Long-term Workforce Recruitment Plan

The Trust has been actively working to recruit more paramedics into the service in order to increase
the resources it has available to respond to the higher volume of emergency calls which it is required
to deal with in the present climate. The Trust has always had a workforce plan in place however new
strategies have since been introduced after the Trust discovered in/around mid-2014 that more
paramedics were leaving their employment than the numbers being recruited to fill vacancies.

At this stage, the Trust has recruited 104 student paramedics and 204 emergency care assistants
since January 2014. In addition the Trust has planned to recruit an additional 40 student paramedics
during 2016/2017. The Trust has also recruited 31.5 qualified paramedics and will continue to recruit
in this role with a healthy pipeline. The emergency care assistants and technicians will support
paramedics in attending emergency calls, including driving the ambulance and assisting with medical
intervention, having been trained in basic life support.

At the same time, the Trust has been transferring advanced technicians to frontline operational roles
in order to reduce frontline pressures for lead clinicians. 20 members of staff have so far agreed to
this. Advanced technicians, like paramedics, are trained to deal with life threatening illnesses and
injuries. They are therefore very experienced members of staff. However, paramedics are also
trained to undertake invasive procedures which may need to be performed during the most serious
medical emergencies, including intubation (where a tube is inserted into the windpipe to help a patient
breathe) and cannulation (where a thin tube is inserted into a vein in order to introduce fluid and drugs
as quickly as possible).

The Trust has also implemented a paramedic bank for recent Jeavers, whereby qualified paramedics
who leave the Trust's employment, are asked whether they are interested in joining the Trust's
paramedic bank. This is designed to increase the number of qualified paramedics available to fill
vacant shifts. The Trust proceed to complete recruitment checks on these individuals and will provide
updated training for ex-members of staff who join the paramedic bank. It was initially anticipated that
these individuals would be available to undertake frontline clinical duties from around May 2015.
Given the recruitment pressures which the Trust has faced, this was pushed back slightly, however
the paramedic bank has been in place since around October/November 2015, therefore allowing
cover for the winter pressure period.

Moreover, the Trust had also placed an advert for qualified paramedics in the periodical "Ambulance
Life" which has an international reach and has been pursuing other international recruitment
campaigns. This has resulted in the recruitment of 19 paramedics from Poland, with 4 individuals
ready to commence front-line clinical roles and the remaining 15 currently being processed.

As noted above, one major issue faced by Ambulance Trust's nationally with respect to recruitment is
the fact that all would-be paramedics have to undertake a 2 year training course at University, which
effectively means that the Trust has to recruit 2 years in advance of employment commencement. As
such, and in order to attempt to tackle the resource shortfall, the Trust has increased the number of
places on its 2 year in-house graduate training programme from the usual 24 places to 48 places, with
a two-stage intake in February and April. This results in the Trust having a year-end forecast number
of student paramedics of approximately 100. The Trust have also visited universities in an attempt to
recruit paramedics who are pursuing their studies but are not yet linked to a particular ambulance
service upon qualification. An arrangement has also been negotiated with Sunderland University
whereby they will train paramedics as and when requested by the Trust and not just in line with the
academic year in order to help match our demand.

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The Trust has consequently maximised its recruitment capacity for student paramedics in university
training. In light of this, and with the increased numbers of student paramedics able to enrol onto the
training programme, the Trust should increase its future paramedic resource baseline, whilst student
paramedics are also able to gain invaluable work experience by working alongside qualified 'mentor’
paramedics. Student paramedics will effectively be operating as emergency care assistants and are
coupled with a fully qualified paramedic on a double crewed ambulance.

The Trust has also recruited a total of 56 Emergency Care Clinical Managers (ECCMs) who have
been recruited from the current team leader pool. ECCMs manage the Trust's ambulance stations
and ordinarily spend 90% of their time undertaking management/supervisory/governance work, with
the remaining 10% on the front line. However, in order to help ease frontline pressures in the current
climate, the ECCMs will spend 50% of their time working on the front line and will be able to cover a
number of shifts.

In addition, the Trust has been looking to increase the number of PTS (Patient Transport Service)
staff. A PTS member of staff transports patients to and from planned appointments at a range of
healthcare providers. Our PTS staff are now fully integrated into the Trust's workforce system and are
allocated jobs appropriate to their skill base. This should help free up the Trust's more experienced
and qualified paramedics to deal with the most urgent emergency calls.

The Trust's emergency crews are required to work twelve hour shifts and as part of the European
Working Time Directive, as well as pursuant to the Trust's role as a responsible employer, the Trust
have to require staff to take rest periods. At such times, the crews are stood down and are not part of
the planned response to emergency incidents, except in exceptional circumstances.

The question as to whether staff should be available to respond to calls during their statutory meal
break has been debated extensively by the Association of Ambulance Chief Executives and with the
Secretary of State for Health. We have held detailed discussions with other ambulance services about
this issue also. The Trust have now proposed to the paramedic Unions that crews should be asked
whether they will agree to cease their meal break in order to attend life threatening Red 1 (8 minute
emergency response) calls. This proposal was initially rejected by the Unions. However, we have
continued to seek the Unions’ engagement on this issue and both Unison and GMB have since both
agreed in principle for their members to be asked to volunteer to respond to R1 cails while they are on
their break. The Trust is currently working through the details of this new arrangement and aim to
have this in place during May 2016.

In addition, there was to be a change to the meal break policy across the Trust PTS team in order to
enable staff to be able to take their meal breaks at locations away from their base stations and at
other sites. Pursuant to the previous meal break policy, staff returned to their own base stations in
order to have their compulsory meal break and were effectively unable to respond to any incoming
calls during this period. The aim was therefore to reduce travelling time going to/from base stations
and to improve resource allocation and utilisation of staff time by reducing travelling. Such changes
were also intended to reduce vehicle usage, with less fuel and vehicle maintenance being required,
therefore allowing the Trust to keep more vehicles on the road to attend emergency calls.

On a separate note, the Trust has been planning for some time to implement a new overtime policy
which would see an increased number of paramedic resources being available across all shifts. This
has taken a while to implement as a consequence of extensive negotiations with the Unions however
the Trust anticipate such a policy being introduced very shortly.

In addition to those measures set out above, in the long term, the Trust has been looking to increase
its own recruitment capacity, by employing more staff in recruitment, human resources and training
roles. This will enable new staff to be recruited and trained in a timely manner in order to fill frontline
vacancies. This remains the case.

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Interim Operational Resource Availability Measures

The Trust have also implemented an interim Operational Recovery Action Pian, which focuses on
short term solutions to deal with operational resource availability and is expected to increase the
Trust's resources on a day to day basis by utilising third party providers to fill current vacancies. A
number of initiatives have also been implemented to increase efficiencies within the emergency care
system to improve response times to low priority calls (i.e. calls which are not categorised as a red '8
minute’ emergency response).

Third party agencies on the Trust's local framework continue to be utilised on a daily basis in order to
provide support and to assist with responding to G2 (30 minute) and low priority emergency and GP
urgent calls, which are within their capability. Third party providers on the framework are trained to an
equivalent level as a Trust Ambulance Technician or a Trust PTS Assistant. The Trust is still currently
seeking qualified paramedics from third party providers as a further short term solution to increasing
higher skilled operational roles whilst recruitment continues pursuant to the above mentioned
Workforce Plan. Using the Trust's local third party framework, an agreement has been reached
where our third party partners can be drawn upon to cover short falls in emergency and urgent care
resources, where necessary.

Third parties provide crews, vehicles and equipment. Although vehicle availability and equipment is
not generally an issue at the Trust, on average 25 double crewed third party vehicles and crews are
available to the Trust to cover rota lines, (i.e. the working rota which is used in order to ensure that
there is a sufficient number of qualified staff available to meet service demands). Additional vehicles
and crews have been made available during the winter pressure periods. These third parties can
cover vacant shifts in order to alleviate pressures on the front line and are allocated appropriately and
in accordance with demand. This continues to be the case.

Additional Measures

Furthermore, the Trust has introduced other initiatives which are designed to alleviate the pressures
on front line resources and achieve faster response times to emergency calls. For instance, in
December 2014, a memo was sent to all dispatch staff which noted that with immediate effect, a G2
(30 minute) disposition would be upgraded to a G1 (20 minute) response for patients 65 years of age
and over, who had suffered a fall and had waited for one hour longer than the original G2 disposition
(i.e. 1 hour 30 minutes in total).

Furthermore, from 7 January 2015, with immediate effect, any G3 (1 hour) disposition that has been
waiting for an additional hour past the original 1 hour disposition time (i.e. 2 hours in total), is
automatically upgraded to a G2 (30 minute) response.

Finally, since late September 2014, any G2 (30 minute) road traffic collision call received from the
police that has breached the 30 minute disposition time has been automatically upgraded to a G1 (20
minute) disposition. The aim of these new protocols is to build in safeguards around waiting times
where possible.

Furthermore, the Trust has been working closely with the local Clinical Commissioning Groups to
sustain and improve the provision of patient care over the winter periods through specific winter
projects. A winter care plan was in place to help alleviate the additional seasonal pressures. The
Trust has also undertaken a review of its agency and partnership arrangements in order to determine
if current arrangements can be improved. These measures are aimed at maximising patient care
within the home environment, where appropriate, in order to avoid unnecessary Accident and
Emergency Department attendances. This is designed to increase Trust emergency ambulance
resource availability. The Trust also continues to engage with other providers/pathways in order to
manage patients outside of hospital, where appropriate.

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Ambulance Hospital Delays

As noted above, another issue which has impacted on ambulance resource availability is where crews
are tied up at hospital when handing patients over to A&E staff.

The Trust once again deployed Hospital Ambulance Liaison Officers (HALOs) across the region
during the winter period, in order to assist both hospitals and ambulance crews during times of
pressure. The HALOs ceased their role in March 2016. This responsibility has now been taken up by
the ECCMs who undertake this role throughout the rest of the year.

The role of the HALO is to work in partnership with the Emergency Department practitioners at the
local hospitals in order to support the effective and efficient management of patient streams,
particularly patient handover and ambulance turnaround times within the A&E Department. The
HALO will act as an initial point of contact for the ambulance crews, establish the condition of the
patient and liaise with the Emergency Department staff, if suitable, in order to re-direct/refer the
patient elsewhere, such as an Urgent Care Centre, should this be appropriate. The HALO will also
anticipate any potential problems within the hospital's Emergency Department which may impact on
ambulance turnaround times and will work collaboratively with the relevant staff within the Emergency
Department in an attempt to prevent the escalation of such issues.

The HALO will also liaise closely with the Trust's Contact Centre, enabling the Trust to work in a more
proactive manner before delays or issues exacerbate. In addition to the above, hourly updates will be
provided by the HALO to the Trust's “flight deck" in the Contact Centre with respect to bed availability
in the particular hospital's Emergency Department.

The HALO role is deployed at specific hospitals as and when pressure in the system requires their
support in assisting with patient handovers. The role of the HALO is carried out by an experienced
Trust staff member who has undertaken this role previously. The aim of this measure is to improve
operational efficiency and performance to allow crews to become available earlier and to respond to
the next incident sooner than would otherwise have been the case.

The Trust has found the initiative to be of benefit in terms of improving ambulance hospital turnaround
times.

Similarly, the Trust has sought to make use of dedicated Ambulance Resource Assistants (ARAs)
over the recent winter periods, who play a key role in supporting the utilisation of our front line
emergency and PTS crews by ensuring equipment and consumables are restocked at hospitals and
operational stations, thereby reducing the need for crews to travel back to core sites to restock, losing
valuable operational time which could be spent responding to incidents. The ARAs also ensure that
vehicles are transported to the appropriate locations for the commencements of shifts, thereby
maximising the utilisation time amongst crews responding to incidents. The intention behind this
scheme is to improve performance since more crews will be available to respond to incidents, being
resourced with drugs/equipment and will be in the correct place at the correct time for the
commencement of their shift. This will also enable the reduced down time of vehicles having to travel
back to base to restock and reduce the number of delayed shift commencements due to non-
availability of vehicles. The Trust will continue to review and evaluate the benefit of this scheme going
forward.

Finally, the Trust are also continuing to utilise Advanced Paramedic Practitioners (APPs). These
clinicians have proven advanced patient assessment skills of the same level as Emergency Care
Practitioners and are able to assess, treat and in most cases, ensure that the patient is safely treated
at home, where appropriate. As a result, suitable patients are assessed and treated by APPs in their
own home if this is more appropriate than a transfer to hospital. This forms part of the Trust's focus on
improving patient care and experience, as well as to reduce the demand on front line emergency
crews by recognising the importance of ensuring that only those patients who are in need of a hospital
admission in an emergency situation receive an emergency ambulance disposition.

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Going Forward

In light of the above issues, all ambulance services across the country, including the Trust, are
pursuing various workforce recruitment strategies in an attempt to increase their emergency care
resource base. Over the last 12 months, the Trust has improved its paramedic resource base and
attrition rates have improved, whereby there are now more paramedics commencing roles at the Trust
than the number of staff leaving employment. At this stage, the Trust has a skill vacancy of around
20% which has reduced from 25% The Trust's attrition rate has therefore improved in comparison to
other ambulance services across the country. However, there still remains a shortfall of people
entering the paramedic profession nationally. As such, the Trust will continue with its workforce
recruitment strategies which go beyond ordinary workforce planning.

Road Closures and Diversions

The Trust does not always get informed of road closures by the Highways Department. However the
Trust works as closely as possible with other agencies, for example the fire and police, who will
provide intelligence in relation to road closures where these are known. In addition, when a crew
handover takes place any road closures or other issues with highways are put into the shift report so
that incoming crews are aware of various local issues.

The Trust's satellite navigation system, Terrafix, does not alert the driver of the ambulance to road
closures. The route taken is selected by either local knowledge or by the route suggested by the
Terrafix system where a crew is working out of area. However, the Trust will pass on as much local
information as it can to crew members where the Trust has this information.

We hope that this addresses the matters of concern which an have highlighted. If we can be of any

further assistance please do not hesitate to contact Head of Risk and Regulatory
Services at the Trust.

Yours faithfully

oo ane Onmiton

Yvonne Ormston
Chief Executive

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