Sarah Tyler

. £® Preswylfa, Hendy Road, Mold, Flintshire CH7 1PZ

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OB Betsi Cadwaladr Preswylfa, Ffordd Hendy, Yr Wyddgrug, Sir Y Fflint

University Health Board CH7 1PZ
Private and Confidential Ein cyf / Our ref: RS/NT/R28/SAT

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MN oo entins for North Wal Eich cyf / Your ref:

enior Coroner for No ales

HM Coroner’s Office : 01352 808204

County Hall Gofynnwch am / Ask for:
Wynnstay Road E-bost / Email:

Ruthin Dyddiad / Date: 215 March 2017
LL15 1YN

Dear Mr Gittins

Re: Regulation 28 Report to Prevent Future Deaths — Inquest of Sarah Ann Tyler
(DOB 21.04.75 DOD 11.02.15)

We are writing in response to your Report pursuant to Regulation 28 of the Coroners
(Investigations) Regulations 2013, dated 13" January 2017.

There are two matters of concern set out in the Report of 13! January;

1. That there are invariably delays in admission to hospital as there are insufficient beds
available to accommodate all admissions.

2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers
of patients being discharged from hospital.

Introduction

The Health Board recognises the need for improvement and the importance of ensuring
that inpatient beds are available when required for new admissions. Waiting times for new
attendances at the Emergency Department are monitored through the Welsh Government
target for patients being treated or admitted within 4 hours. During Q3 2016/17 78.9% of
patients were treated or admitted within this time.

Whilst the majority of patients are treated or admitted within the acceptable time, a
significant minority took longer to be treated or admitted and a proportion of these will have
waited significantly longer. The Health Board is required by Welsh Government to have a
plan in place so that performance against the 4 hour target is improved, and that more
patients are treated or admitted within 4 hours. The plan to achieve this improvement is
set out in the Health Board’s plan for Unscheduled Care Plan, which is a chapter within the
overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached
in appendix 1. (The plan is a draft at this stage pending feedback on the draft from Welsh
Government).

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive:
Swyddfa'r Gweithredwyr / Executives’ Office

Carlton Court, St Asaph Business Park

St Asaph LL17 0JG Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

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Betsi Cadwaladr
University Health Board

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The Unscheduled Care Plan (appendix 1)

The Unscheduled Care Plan sets out the main changes planned to ensure that waiting
times in the Emergency Department are reduced. The plan describes a change in the
overall approach to providing Unscheduled Care services, which will ensure that there is
both less reliance on admission to hospital in order to receive treatment or care and faster
discharge from hospital when patients could be more safely cared for in another setting or
at home. The combined effect of admission avoidance (reducing demand) and reducing
length of stay (increasing the supply of available bed days) beds will be available more
quickly for patients when they are most in need.

Admission Avoidance

Patients attend ED as a method of gaining access to health services. The Unscheduled
Care plan sets out the overall approach to ensuring that wherever possible, patients can
be treated without requiring admission to a hospital bed. The plan describes how
community services and hospital services will be provided jointly so that patients will be
provided with the same community services, irrespective of whether they present to our
services through the GP or via the Emergency Department. For example, if a patient who
is already known to community services attends ED, the District Nursing team are
automatically informed and will attend to review if the patient can be cared for at home.
This change was implemented in February 2017 at the Maelor hospital and is an example
of measures being introduced to ensure that, wherever possible, the community and
hospital teams will work together to ensure that patients are care for at home. Further
detail on the admission avoidance programme and the targets for improvement are
included within the Unscheduled Care Plan.

We do recognise that it is unsatisfactory for any patient to wait for admission and do
undertake to assess every patient waiting in an ambulance as soon as possible after
arrival and at 30 minute intervals thereafter. This triage assessment is undertaken by a
skilled triage nurse and at times by an emergency department doctor. Where clinically
required we will prioritise the sickest or most unstable patients for transfer into the
department and ensure that patients and those with them are offered refreshments while
they are waiting. We also undertake a daily retrospective review of all patients who have
waited in an ambulance for longer than an hour. We continue to review this process in
order to minimise the inconvenience and eliminate harm.

Reducing Length of Stay

In addition to the work to reduce admissions, there is also a significant focus on reducing
the time spent in hospital for patients that are admitted. Patients who experience a
Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a
support package to be provided in their own home. The Health Board carried out a
detailed joint assessment of the issues that cause delay in December 2016 jointly with
Local Authorities and the Independent Sector providers of care services (care home and
home care). The plans to reduce DTOCs and length of stay are set out in the plan.

Lay G IG Bwrdd lechyd Prifysgol

Betsi Cadwaladr

U
OF S University Health Board
WALES

Bed availability at weekends

The Health Board does also ensure that doctors and discharge teams are available to

support at weekends but, in the absence of a whole scale change in working practices,
there will continue to be differences in the way that the hospital operates on a Sunday

compared to other days in the week.

The main Health Board response to this issue is to ensure that the overall level of bed
occupancy is reduced. The availability of hospital beds at weekends is largely depended
on how well the system operates throughout the rest of the week. The aim of the
Unscheduled Care plan is to ensure that there are beds available at all times and the
recognised standard for the level bed occupancy required to achieve this is 85% Bed
Occupancy. This means that there are 15% of beds available for new admissions and
achieving this level of occupancy enables the hospital to cope with a level of natural
variation in activity over the weekend. The combined approach of reduced admissions
and reducing length of stay has been modeled to enable the target level of bed occupancy
to be achieved.

The Unscheduled Care Plan sets out the targets set by the Health Board in each section of
the plan and the whole of the plan will be implemented within 2017/8. The implementation
of the plan will be overseen by the Health Board wide Unscheduled Care Transformation
Group, which is supported by local implementation groups and projects charged with
delivering each element of the plan. There will be monthly updates within the Health
Board on the progress of the plan and progress against the plan will be monitored by
Welsh Government.

The Health Board is determined to improve the experience of patients that require urgent
admission to hospital and the Unscheduled Care Plan sets out that changes that will be
implemented to ensure that his will be achieved. The implementation of the Unscheduled
Care Plan is an important element of the overall Operational Plan to improve operational
performance and the Health Board will be performance managed by Welsh Government
over the delivery of this plan.

Please contact us if you require any further information.

Yours sincerely

a

Executive Director of Nursing and Midwifery

Enc