Rebecca Evans

Q Block 5, Carlton Court
'4 ~y G IG Bwrdd lechyd Prifysgol St Asaph Business Park
élfes CYMRY | Betsi Cadwaladr St Asaph
& fo University Health Board Denbighshire
WALES LL17 0JG

Mr John Gittins Ein cyf / Our ref: GD/CB/3405/777

Senior Coroner for North Wales (East and Eich cyf/ Your ref:

Central) @: 01745 448788 ext 6364
Coroner's Office, County Hall Gofynnwch am / Ask for:
Wynnstay Road E-bost / Email:

Ruthin

Denbighshire Dyddiad / Date: 25" April 2017
LL15 1YN

Dear Mr Gittins,

RE: Emergency Care Access Performance

write in response to the Regulation 28 of 14° March 2017 highlighting performance
issues relating to Ambulance handover delays.

Matters of concern:

1. That there were significant delays in the admission of Ms Evans to hospital and the
medical treatment was consequently not commenced in a timely manner.

2. That despite changes having been made previously the current practices in place
for the handover of patients at an Emergency Department far too often results in
wholly unacceptable delays with patients being kept waiting for long periods in
ambulances and ambulances 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.

| will detail below the improvements we have made or are in the process of making to
improve waiting times in our ED but in terms of performance we have made
improvements in what is our busiest time of year. Comparing January to March 2017 to
the same period last year shows improvements in every indicator (e.g. 4 hours, twelve
hours, and response times for Red ambulance calls. For ambulance handovers taking
more than an hour, the number has improved substantially - a reduction of 786 instances
which is a 23% improvement.

Unscheduled Care Plan

The latest version of the Unscheduled Care Plan included within our 2017/8 Operational
Plan submission is attached. The plan covers all areas of the Unscheduled Care System
and has been developed to ensure improvement in emergency access, as measured by
the 4 hour and 12 hour target.

The plan addresses the main causes of Unscheduled Care pressure through reducing
admissions (demand), reducing DTOCs and length of stay (supply) and addressing flow

at the front of hospitals to protect minors from long waits. It also includes reducing
ambulance handover delays.

The overall plan is supported by a set of metrics which will demonstrate improvement on
the underlying position which will lead to improved 15minute ambulance handover.

The work in these areas is showing improvement in reducing admissions and DTOC.
There is clearly a great deal more to do, but | can assure you that these improvements
are a key priority for the Health Board.

Engagement at an Executive Level

| have taken steps to strengthen the level of visible Executive input to the management
of escalation out-of-hours and nominated Morag Olsen as our lead Exec to link with the
Welsh Government Delivery Unit to explore areas where further improvements.

The use of information within Unscheduled Care decision making

There is extensive use of predictive tools and modeling within our overall approach to
Unscheduled Care. The overall capacity and demand model developed by the planning
section has informed the scale of improvement required to achieve a bed occupancy level
of 85%. The metrics within the overall plan are calibrated at a level which has been
calculated to enable the 4 hour target to be achieved and improve ambulance handover.

On a daily and weekly operational level, there is extensive use of demand and flow
information in Unscheduled Care decision making. In particular, predictive demand
analysis is used to drive resourcing decisions within each week. The following is a
sample, but not a complete list of the information routinely used:

Daily and weekly 4 hour/12 hour performance

Daily and weekly activity trends

Ad —hoc trends for holidays and peak periods

Time spent in ED

Heat maps of arrivals and ED occupancy

Frequent attenders

e Review of ambulance performance against quality standards

The majority of the above is held on the main information system (IRIS), which is in
extracted to support weekly decision making on Unscheduled care.

The following are examples of operational decisions which have been influenced by the
above information specifically in relation to improving performanceat YGC and YMH:

{. Medical Rotas; WMH has increased Emergency Department Consultant presence
overnight on the shop floor. YGC has a second ED Consultant on the shop floor
until 10 pm. These rota changes are set against a challenging workforce
recruitment and sustainability backdrop

Nursing Rotas; Since YGC opened the new Emergency Department in June 2014
the nursing staff have been significantly increased to ensure staffing meets demand
especially in the evening, weekend and over night. WMH have increased twilight
shifts to meet evening demand. Both WMH and YGC Emergency Departments
have increased their Health Care Support Workers capacity and increased
Physician Assistant roles to meet demand and improve timeliness.

GP Out of Hours; both YGC and WMH have worked to create an integrated
platform to deliver services that support patients moving from ED to GP Out of Hours
to reduce demand on the minors ED streams. This redirection continues to evolve
with further work supporting satellite GP Out of Hours facilities co-located with Minor
Injury units for example at Llandudno Hospital.

Emergency Departments and WAST; WAST locality Leads are engaged on both
sites supporting non-conveyance options for EMS activity. This includes the formal
Minor Injuries Units Stand Operating Procedure to redirect suitable clinical cases to
MiUs.

Alternative Healthcare Professional provision; Both Emergency departments
have responded to the Musculo-skeletal demand attending the departments by
appointing Extended Scope Physiotherapists. YGC has also employed through
seasonal plan funding GP support to ED to stream suitable patients away from the
main emergency department pathways.

Emergency department Capacity; both EDs have reviewed the demand profiles
and commissioned additional clinical capacity. WMH have opened two additional
examination rooms for minor attendances to protect the minors stream. YGC have
converted one minors trolley space to a four chair ambulatory area to increase
minors stream capacity.

Operational site management; WMH have employed twilight site managers to
support evening bed pressures. All three acute hospitals in the Health Board are
moving towards a new out of hours site management clinical rota to support flow
and response to escalation. This includes additional night sisters to support core
site management. WMH also provide a Senior Manager of the day who works till
8pm to support decompression of acute problems affecting flow.

Ambulance Conveyances; YGC has engaged with Public Health Wales to
understand the higher 999 demand experienced at YGC. This work is informing a
number of plans including the development of a minor injuries unit within the north
Denbighshire project at the Royal Alexandra hospital site.

Frequent service Users; data on both Emergency Department attendances and
acute admission into medicine from frequent service users (more than 4
attendances / admissions in a rolling 12 months) has resulted in resources being

10.

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allocated to clinical Psychology to lead a multi-disciplinary response to the most
frequent service users. This results in a multi-agency action plan. Benefits are felt
within the acute hospitals, WAEDT and north Wales police.

Senior Manager Bronze and Silver on call arrangements; a formal review of
Bronze and Silver on call manager rotas in recognition of the demands of
unscheduled care pressures has informed the development of a new model. This
includes

Dedicated Silver on call for 24 hours

Development of complimentary clinical rota to support sites de-escalation
and risk management

c. Strengthened site management resilience with additional night Sisters to
support flow

oe

Evening / Overnight Capacity; all sites have developed surge capacity options to
meet periods of peak demand during the evening and overnight. This utilizes
physical capacity that would not normally be staffed overnight, therefore increasing
capacity and utilization of core clinical estate.

Development of Medical Fit to Discharge data; WMH and YGC have used data
extracted specifically from WPAS and local data collection to identify patients fit for
discharge but delayed due to factors outside of the acute hospital control. This has
resulted in the development of new escalation pathways and teams, such as the
Step Down Team at YGC to secure alternative discharge / transfers options for
MFDs contributing to bed blockages and bed turn over.

Patient Navigators at YGC Emergency Department; learning from Salford
Hospital has been implemented at YGC through using patient navigators to help
redirect and expedite patient care of walk in attenders.

Roll out of treatment escalation plans (TEP’s); a completed pilot of treatment
escalation plans for palliative/terminally ill patients in Nursing and residential homes
has resulted in a 50% reduction to referral to the emergency department and is now
being rolled out across BCU.

Regular Review of Patient delayed in Ambulances; to help prevent recurrence
of the issues you raised relating to Rebecca Evans a system of regular checks,
diagnostics and treatment, has been put in place to ensure patients experience the
minimum delay.

Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST)
they co-ordinate with emergency department to ensure that ambulances can be
released to respond to potentially life threatening calls through immediate offload
into any available in ED.

The above are just examples, but are offered to illustrate the level of daily and weekly
scrutiny of demand and Unscheduled Care pressures.

The Health Board fully accepts that its current unscheduled care performance, though
demonstrating an improvement on this period last year, must improve both in terms of
giving our patients and our staff the experience they should be receiving. | expect the
move to a position of improvement rather than deterioration to be an important turning
point which acts as a springboard to build on. | hope this letter offers the required level of
assurance that we are focused on taking action to address the performance issues raised
in your letter. Please let me know if you would like further detail on any of the areas within
my response.

Yours sincerely

Gary Doherty
Prif Weithredwr
Chief Executive

Enc