Daphne Williams

Block 5, Carlton Court
7 G IG Bwrdd Iechyd Prifysgol St Asaph Business Park
Ge XY iM U | Betsi Cadwaladr St Asaph
‘vere: Boar enbighshire

XOF Wes University Health Board LL17 OJG

Mr John Gittins ;

HM Senior Coroner for North Wales (East & Ein cyf / Our ref: GD/

Central) Eich cyf / Your ref:

van rat 4 @: 01745 448788 ext 6364

nnstay Roa
Ruthin y Gofynnwch am / Ask for:

LL15 1YN E-bost/ Email:

Dyddiad / Date: 31° July 2017

Dear Mr Gittins

Re: Report for the prevention of future deaths
Inquest of Daphne Edith Williams

This is a joint response to the Report pursuant to Regulation 28 of the Coroners
(Investigations) Regulations 2013, dated 25 May 2017 for Daphne Edith Williams, which
was issued to Betsi Cadwaladr University Health Board (BCUHB) and Welsh Ambulance
Services NHS Trust (WAST).

This response has been prepared collaboratively between BCUHB and WAST.

The letter outlines the actions being taken in response to the matters of concern you
outlined in the recent Regulation 28 notification for Daphne Edith Williams, namely;
ambulance delays, admission to ED, availability of resources and patient flow. All
agencies are also aware of other Regulation 28 notifications that have been issued
relating to patient flow issues to BCUHB, Local Authorities and WAST for Lilly Baxandall
(17 May 2017) and to BCUHB for Catherine Haf Roberts (7 July 2017) to which the
actions outlined within this letter also apply, but for which separate formal responses will
be submitted from the relevant organisation(s).

The local authorities have not been party to any involvement regarding the previous
reports issued and are therefore unable to comment on the content of the responses
previously sent or indeed the actions referred to.

(Please note, the local authorities will comment later in this response on those areas that
may be of assistance to support cases such as these.)

In reviewing the action plans already submitted in response to previous Regulation 28
reports relating to patient flow, BCUHB notes that all previous actions have been
implemented or are work in progress, with the exception of the establishment of a North
Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of
improving access for acute hospital admissions across North Wales due to geography
and enabling the admission of emergency patients to as local a hospital as possible, as
often as possible.

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

Ysbyty Gwynedd, Penrhosgarnedd

Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

Bwrdd lechyd Prifysgol

Betsi Cadwaladr

Lo University Health Board
WALES

In response to the matters of concern raised in the Regulation 28s for Daphne Edith

Williams, BCUHB and WAST have structured their response along key elements of the

patient pathway, these being:

e Avoidance of Ambulance Conveyance / Emergency Department (ED) attendance /

Hospital Admission

Improvement in Handover Times of patients conveyed to EDs by Ambulance

Improvement in ED patient flow and timely assessment of patients

Improvement in internal hospital flow to ensure more rapid admission of patients from

ED who require this

e Improvement in the discharge/transfer of care of patients at the end of their acute
hospital stay.

Our response reflects and compliments the actions outlined in the BCUHB 2017/18
Unscheduled Care plan. BCUHB also recently held 3 Unscheduled Care Summits with
clinicians and colleagues from partner agencies to discuss and agree specific focussed
actions to improve the provision of unscheduled care services. In December 2016 the
cross sector chief executives issued a directive for a detailed analysis of the care sector
pressures resulting in an intensive 5 day work programme led by Director’s in both health
and the local authorities. This work resulted in a comprehensive action plan which is in
place to address some of the blockages in the system that contribute to delayed
discharge.

In addition through the spring and summer 2017, BCUHB, WAST and key partners have
held a number of events with frontline staff to examine, explore and find solutions to the
current service pressures, these were called Innovation Unblocked. Through these
engagement events staff have identified very practical solutions of how systems can be
improved to support flow. These events have also identified key pathways that need to
be developed to avoid hospital admission or to improve patient access to the right
services avoiding unnecessary attendance to the Emergency Department.

To compliment this work, the Delivery Unit (DU), is also supporting BCUHB to implement
improved risk escalation systems in managing unscheduled care demand. This is initially
focussed on acute hospital sites to increase patient safety. The DU is initially focusing
on providing this support at Ysbyty Glan Clwyd.

1. Avoidance of Ambulance Conveyance / ED Attendance/Hospital Admission

In October 2015 WAST introduced a new clinical response model to implement new ways
in which callers to 999 are assessed. This sought to ensure that patients and users of the
service received the most appropriate care and a response to suit their individual needs.
The changes made clearly identify those patients who require an immediate life-saving
response and these patients receive the highest priority response in the fastest possible
time.

All other patients receive a bespoke clinical response based on their condition, rather
than a response based solely on a time standard. These changes sought to improve the
patient's care, outcome and experience, as well as improve patient flow into hospitals.

GIG | swrad techyd Prifysgol
CYMRU

Sy? YMRU | Betsi Cadwaladr
oe W H University Health Board

WAST has been working with BCUHB to develop new services and alternative care
pathways. Latterly, this has included holding a series of joint, clinically focused
workshops across North Wales to review, identify and implement new emergency care
pathways that WAST can access, some of which have been agreed in other parts of
Wales. The final workshop took place on 7 July following which a number of key
innovations, work streams and care pathways have been prioritised. A clear priority
identified will include having a focus on improving the management and care of patients
who fall at home (referred to separately in more detail later in this section of the
response). The detail of the Unblocking Innovation events is attached as Appendix 1.

In addition, and in line with the BCUHB Unscheduled Care Plan 2017/18, WAST has

been focusing on:

e Increasing Conveyances to Minor Injury Units to reduce demand on EDs

e Increasing the effectiveness of the WAST Clinical Support Desk

e Improving support for frequent callers to WAST to reduce ambulance conveyances to
hospital.

e Developing the provision of alternative care pathways

e Enhancing WAST Clinical Leadership

1.1 Minor Injury Units (MIU)
The Head of Operations for WAST has been leading work with BCUHB to increase the
access to and use of MIUs by WAST, supported by a joint steering group which aims to:

Ensure a nurse led MIU service is available across all of North Wales

Improve patient access

Review and extend the admission criteria

Extend opening times, particularly over the busy periods

Launch an “App” to ensure that the opening times of the MIU are publicised for WAST
responders and the public.

The next steering group meeting is planned for September 2017 when work to date will
be reviewed to ensure progress in all areas.

1.2. Increased effectiveness of the Clinical Support Desk

As the result of a service improvement initiative, WAST has invested in a Clinical Support
Desk within the Clinical Contact Centre (CCC). This means that a clinician (nurse /
paramedic) is available to clinically assess, through telephone triage, the needs of
patients and advise on appropriate alternative care pathways or conveyance. This
initiative has proved highly successful, resulting in an average of 2,500 calls per month
having a non-ambulance outcome, thereby substantially reducing ambulance
conveyances to hospital. Following the success of this initiative, WAST has successfully
presented a business case to the Ambulance Services Commissioner and Welsh
Government and has received funding from Welsh Government to increase the clinicians
employed in the clinical support desk for up to 30 whole time equivalents. Some clinicians
are now located on the North Wales Clinical Support Desk in the CCC.

IG Bwrdd lechyd Prifysgol
A Betsi Cadwaladr

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24 S University Health Board
WALES

1.3. Frequent Caller Initiative

A number of patients repeatedly access the 999 emergency ambulance service where
alternative care may be more appropriate for them. These individuals often have complex
health and / or social needs and may have disengaged from appropriate care services.

Across Wales, WAST has already worked successfully with other Health Boards to
provide appropriate alternative care for frequent callers within communities without the
need for a conveyance to ED. A joint work stream between WAST and BCUHB has now
been established to introduce a similar service in North Wales.

1.4. Provision of Alternative Care Pathways

WAST and BCUHB are working together to proactively manage more patients within the
community setting, reducing unnecessary conveyance of patients to hospital. During
quarter (April, May, June 2017) the Ambulance Quality Indicators confirm that a
conveyance rate of 64-65% of patients to hospital across BCU. This is the lowest
conveyance rate across all Health Boards in Wales. Examples of improvement work to
achieve include the management of patients who fall at home, patients with a mental
health need and the implementation of the Paramedic Pathfinder:

e Falls: The Clinical Support Desk is working collaboratively with Wrexham Fire Service
and North Wales Police to provide care and assistance to non-injury fallers within the
community setting. The fire service will respond and assist the patient and while doing
so, undertake preventative work including surveying the house for any immediate fall
hazard risks, security and fire prevention.

As a result of the joint clinical workshops referred to earlier in this response, WAST
and BCUHB will implement a North Wales wide falls pathway by the end of October
2017.

WAST has established a falls strategic improvement group to focus on improving the
assessment and response to patients who have fallen across the 5 step model to
inform a ‘once for wales’ approach to falls.

e Mental Health: As a result of both service user and staff feedback, WAST has
developed a Mental Health Improvement Plan outlining 6 priority areas for those with
mental health needs. This includes supporting WAST staff through the use of an
assessment of the patient’s mental health illness or mental distress. This will be based
on using up to date evidence based education and training and developing risk
assessment tools for frontline clinicians to support their decision making.

In addition, a key priority is to develop alternative care pathways for patients
experiencing mental health distress to ensure that wherever appropriate conveyance
to an ED is avoided. In other parts of NHS Wales, WAST has successfully developed
joint pathways with mental health crisis teams. This learning has been shared with

a GIG Bwrdd lechyd Prifysgol

7 Betsi Cadwaladr
o F University Health Board
WALES

BCUHB and informs joint work underway to develop and implement this care pathway
within North Wales. This approach will need to be discussed further with the local
authorities.

e Paramedic Pathfinder

The demand for emergency ambulance attendance is increasing year on year. Many
patients can be treated through safe alternatives to transportation to an ED.
Paramedic Pathfinder has been designed to support ambulance clinicians in
assessing patients in the pre-hospital environment. It does this by enabling the
exclusion of serious discriminators before any consideration is given to an alternative
pathway of care other than conveyance to an ED. WAST is currently undertaking a
trial of the Manchester Triage System (decision support tool) in the Abertawe Bro
Morgannwg University Health Board area. This will be evaluated for potential future
roll out across Wales to inform alternative pathway development.

1.5. Enhancement of WAST Clinical Leadership

A key priority area for WAST, identified in the service's Integrated Medium Term Plan, is
the development of its paramedic workforce. Following the changes to the WAST clinical
response model outlined earlier, the service is becoming a more clinically focussed
service, requiring the complimentary development of a clinical leadership structure to
support paramedics to work their full scope of practice. This will in turn enable them to
identify more patients suitable for alternative care pathways to conveyance to ED. This
work has already commenced with the appointment of a new Assistant Director of
Paramedicine.

Complimenting this work by WAST are a range of BUCHEB initiatives to reduce ambulance
conveyance//ED attendance. These include:

e Introducing Treatment Escalation Plans (TEPS) to reduce the number of people
brought to EDs by ambulance from nursing/residential homes. These plans outline
alternative care pathways and treatment options for individuals to manage them
safely in their residences.

e Developing enhanced multi-disciplinary community resource teams (CRT) to provide
more care for individuals in their own homes. The CRTs are in varying degrees of
development across North Wales and whilst have the potential to better manage care
closer at home need to build on the range of successful intermediate care provision
already delivered in the 6 local authorities.

e Developing a range of alternative care pathways including for catheter management,
palliative/end of life care at home or in a nursing/residential home and work with
WAST to develop a number of alternative care pathways including one for falls (see
below). One authority already provides a successful palliative care service on behalf
of the health service and the local authorities are keen to enhance services they could
be commissioned to provide.

IG Bwrdd lechyd Prifysgol
Gof CYMRU | Betsi Cadwaladr
- 4 H University Health Board
WALES

2. Improvement in Handover Times of patients conveyed to EDs by Ambulance

BCUHB has developed an escalation protocol to ensure a consistent approach to the
safe management of patients whose handover is delayed. This is to support the
procedure to enable the immediate release of delayed ambulances to enable WAST to
respond to life threatening or clinically urgent 999 calls in the community (the immediate
release system).

With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which
clearly outlines the escalation processes for WAST and BCULB staff to apply to enable
ambulance crews to hand over patients to ED with minimum delay. As part of the ‘LEAP’
protocol, WAST provides a Hospital Ambulance Liaison Officer (HALO) or a Duty
Operational Manager (DOM) at hospitals when ambulances are delayed. These are
usually WAST Clinical Team Leaders whose role is to supervise crews experiencing
handover delays and liaise directly with ED.

The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure
good communications with hospital sites about WAST community activity and demand,
particularly during times of handover delays. Delays are escalated to a WAST senior
manager who liaises with senior BCUHB officers to agree how resources can be safely
released to respond to WAST community activity.

WAST and BCUHB have together developed guidance for paramedics to identify patients
well enough to be placed in the ED waiting room, rather than wait on an emergency
ambulance.

For Ysbyty Glan Clwyd, patients who cannot be immediately accommodated into a
clinically appropriate ED space will undergo a triage assessment by an ED nurse and a
clinical medical review. Patients held in an ambulance for an hour or more will have a full
‘harm’ review to commence assessment/treatment and ensure their care outcome is not
compromised. The recording of patients’ vital signs including the National Early Warning
Score (NEWS) is routinely recorded as part of these assessments and is integrated into
the paramedics’ patient record.

At Ysbyty Maelor Wrecsam, a holding area in ED is created whenever possible during
the day to enable patients of low risk to be handed over without delay by WAST and
brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical
‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid
handover and assessment of patients.

3. Work to Improve Assessment Times / Flow in ED

BCUHB constantly reviews its clinical and operational processes to improve waiting and
assessment times for patients and to admit patients in a timely manner to an inpatient
bed where this is required. BCUHB acknowledges there remains much work to do but
examples of more recent improvements are outlined below.

3.1.

3.2.

Bwrdd lechyd Prifysgol
Betsi Cadwaladr

fo University Health Board
WALES

Ysbyty Glan Clwyd

A review of the use of the physical space within ED has created an open ambulatory
chair centric area with 4 additional assessment/treatment spaces; the
commissioning of 2 additional beds in the observation bedded area of the ED; the
use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am
- 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible
approach, in extenuating circumstances, to the use of all space within the ED during
times of peak pressure.

A further review of the physical layout of the ED is underway to identify space to
create firstly an area to rapidly assess patients handed over by WAST (RATS) and
secondly to better manage the ‘minors’ flow in ED to improve the waiting times and
assessment of these patients.

On-going recruitment of nursing and medical staff is a key focus. This has resulted
in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE,
and an increase in funded medical staff posts to double the posts from 4 to 8 full
time Consultants and from 5 to 8 middle grade senior doctors. It will take time to
attract and recruit substantive staff to all posts although recent recruitment
campaigns for senior medical staff have met with success. It is anticipated that the
Consultant and senior middle grade doctor posts will all be filled with substantive
appointments by the end of 2017. Until this time, the service is employing locum
medical staff to provide as much service cover and continuity of care as possible.
The service is also working towards better matching senior medical staff working
hours with times of peak patient demand. The aim is to have the Consultant late
day shift extended from 18.00hrs to 22.00hrs and have a second Consultant
working until 3pm Monday to Friday

Work is also underway with the co-located GP Out of Hours service in the ED
department to identify more suitable patients through the triage of self-presenting
patients to ED for ‘pull’ into the GP Out of Hours service.

A day time GP, Monday to Friday, is also in place in ED to treat primary care self-
presenters to ED.

Work is also on-going to increase specialty ‘in reach’ into ED by medical and
surgical specialties who attend ED to review patients rather than wait for them to be
admitted to an inpatient ward. This does result in some patients being discharged
home from ED.

Ysbyty Maelor Wrecsam

The recruitment of medical staff is ongoing to improve cover of the medical rota from
August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies
currently covered with locum Consultants. There is a focused campaign of work
ongoing to recruit to these key posts on a permanent basis.

The recruitment of nursing staff has been successful. However, retention of staff
remains a challenge with the senior nursing team focussed on maintaining patient
safety in ED.

yy G IG Bwrdd lechyd Prifysgol
CYMRU | Betsi Cadwaladr

v4 H S University Health Board
WALES

e Medical and nursing staffing rotas have been reviewed and amended to better
reflect the peaks of patient demand in ED and changes have also been made to
increase the senior level cover in the department.

e The ENP service has protected staffing and clinical space to ensure patients with
minor injuries are treated in a timely manner.

e 3 additional rooms in ED have been opened for Minors patients, the ENP service
and GP Out of Hours Services.

e Work is also underway with the co-located GP Out of Hours service in the ED
department to identify more suitable patients through the triage of self-presenting
patients to ED for ‘pull’ into the GP Out of Hours service.

e There is specialty ‘in reach’ into ED by medical and surgical specialties who attend
ED to review patients rather than wait for them to be admitted to an inpatient ward.
This does result in some patients being discharged home from ED.

e A Night Sister post has been put in place to assist the Clinical Site Manager with
patient flow and associated quality and safety issues

4. Work to Improve Site Flow across Ysbyty Glan Clwyd / Ysbyty Wrexham Maelor

Much work is also on-going to admit patients in a timelier manner into inpatient beds from
ED. As with service improvements in the EDs, BCUHB acknowledges there remains work
to do but examples of recent improvements are outlined below.

4.1. Ysbyty Glan Clwyd

e A modified form of unified assessment documentation for patients awaiting
admission from ED has been under development. This supports the provision of
inpatient level type care to ED patients, ensuring their clinical outcomes and
treatment is not compromised. It is intended to fully introduce this process in early
August, following a period of trial to ensure all documentation and processes are
fully fit for purpose.

In early autumn, a Frailty Assessment Unit will be trialled, providing a more
comprehensive assessment of frail patients at the ‘front door’ with the aim of
avoiding admission for some of these by providing additional community support to
enable patients to be safely managed in their own homes. This needs further
discussion with the local authorities.

During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in
line with available staffing. This includes the use of medical and surgical
assessment spaces as overnight inpatient beds and the escalation of additional
beds on some wards where staffing levels enable this to be done safely.

A ‘Step Down’ Manager post has been created who works collaboratively with
community health and social care colleagues to ensure that patients with complex
care needs are moved to the next stage of their care pathway without undue delay
(this may be: placement in a nursing/residential home, transfer to a community
hospital or back to their own homes with packages of support). However local
authorities already provide swift discharge to social care packages and often the

4.3
BC
the

Bwrdd lechyd Prifysgol

Betsi Cadwaladr

oe University Health Board
WALES

choice of the patient in relation to their preferred care settings can contribute to
delay.

. Ysbyty Maelor Wrecsam

From the 18 August 2017, a rapid assessment unit will be operational to assess and
admit patients from ED (and GPs) without undue delay. From the autumn, this will
be complimented with a Frailty Assessment Unit with a focus on admission
avoidance to return individuals to their own homes with the support of community
staff, including therapists. The unit will provide rapid assessment and treatment of
patients who have the potential to return home the same day or within a maximum
of 72 hours. Patients will be treated as ambulatory until proven otherwise and within
the unit, individuals will receive rapid diagnosis and stabilisation before they are
supported home. The ethos of the unit is to proactively diagnose and treat patients;
to prevent deterioration that could lead to an emergency admission; and, to refer to
the appropriate community services to support patients in their own home during
their need for support.

During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in
line with available staffing. This includes the escalation of additional beds on some
wards where _ staffing levels enable this to be done _ safely.
The District Nursing Service in Wrexham is now available overnight, enabling more
patients to be safely cared for at home rather than remain in hospital.

The provision of an IV suite continues to develop as an important service to enable
individuals to receive IV therapy as a day attender (both emergency and elective)
without the need for an overnight hospital stay.

In times of extreme pressure, additional holding areas are staffed away from ED to
assist with the pull through of patients from ED to sustain flow of emergency
patients.

A proposal has also been drafted to provide a Clinical Manager of the Day, 7 day a
week, in addition to the Clinical Site Manager model already in place.

. SAFER
UHB has committed to implement the SAFER bundle in all 3 acute hospital sites over
next 6 months. This is an evidence based bundle of actions shown to reduce length

of stay and support safe patient discharge. The key elements of this are:

Thi

A daily senior review of all inpatients (S)
All patients to have an expected date of discharge (A)

Patients are moved out of assessment areas earlier in the day into inpatient specialty
wards (F)

A third of patients being discharged leave their ward before midday (E)

Regular review of patients who have been in hospital for 14 days or more to identity
actions required to facilitate safe discharge.(R)

s was endorsed by the National Unscheduled Care Board and implemented locally. A

number of elements are already set up (such as reporting key measures i.e. ‘Expected
Date of Discharge’), with work ongoing to fully implement the patient flow bundle, with

Bwrdd lechyd Prifysgol

Betsi Cadwaladr

oS University Health Board
WALES

senior clinical leadership at the helm, and supporting communications. The objective is
to align actions of ward teams (Nursing, medical, therapy and partners) more closely and
deliver actions earlier; this should result in improvements to length of stay (LOS) and
therefore flow. Medical leadership is vital, and job plans will be reviewed in some
cases. Key measures will be:

- Numbers of discharges before 12:00 midday

~ Compliance with Expected date of discharge (with expectations that this should be
> 80% on wards, allowing for new arrivals)

~ Length of stay

A guide for the SAFER patient flow bundle produced by Welsh Government is attached
at Appendix 2 for information.

5. Improvement in the discharge/transfer of care of patients at the end of their
acute hospital stay.

As well as the actions outlined above, BCUHB works collaboratively with WAST and
Local Authorities to support the safe discharge/transfer of care of patients following their
acute hospital stay to ensure patients don’t remain in hospital longer than they require.
At both Ysbyty Maelor Wrecsam and Ysbyty Glan Clwyd, there is a strong focus on early
identification of patients who are medically fit for discharge to ensure timely discharge.
Daily ‘board rounds’ are held across acute adult wards to ensure daily discussion of each
patient and their care needs, including discharge planning as appropriate with local
authority colleagues. There is a weekly review at both hospital sites of patients
experiencing a ‘Delayed Transfers of Care’ (DTOC).

Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic
review within BCUHB which may identify new actions for the Health Board and possibly
its partners to complete to realise improvements to the discharge planning process.
WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation
Guidance’ to ensure that WAST and the wider NHS community fully understand the
process of requesting an ambulance resource for particular groups of patients who need
transport to enable their discharge/transfer to another facility. This will help ensure timely
discharge using the most appropriate resource whilst also maintaining the availability of
WAST resources to respond to 999 calls.

Whilst the Regulation 28 for Daphne Edith Williams was not issued to Local Authorities,
the response that the four Local Authorities provided in relation to the Regulation 28
issued for Lilly Baxandall, outlines the relevant work that is ongoing to prevent and reduce
inappropriate admissions and reduce delayed transfers of care.

Bwrdd lechyd Prifysgol

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We? Betsi Cadwaladr

X37 H University Health Board
WALES

6. Concluding Remarks

We trust this joint response from BCUHB and WAST outlining actions being taken across
the patient pathway provides you with the assurances you require in response to the
matters of concerns raised within the Regulation 28 notice issued for Daphne Edith
Williams. All organisations are committed to working together, sharing learning and
making service improvements to improve patients experience and outcome of care.

Clearly as partners working together we prioritise effective hospital discharge services
and just as importantly preventative services. However we need to acknowledge that
there are some frailties in the provision of care due to national pressures impacting on
care home and home care providers. These do pose some risk to the service which have
been acknowledged on a regional and national basis.

We collectively acknowledge the multi-faceted system changes required by all
organisations in North Wales and will continue to work together collaboratively to improve
the services we provide to our patients and the wider local populations.

Please do not hesitate to contact us if you require any further details or have any
additional areas of concern.

Yours sincerely

/

[jim 7 thom Tra Yy My Ad/

Chief Executive Chief Executive
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust