Richard Barrett

Pencadlys yr Ymddiriedolaeth, Safle H M Stanley, Llanelwy, Sir Ddinbych LL17 0RS 
Trust Headquarters, H M Stanley Site, St Asaph, Denbighshire LL17 0RS Tel/Ffôn 
01745 532900 Fax/Ffacs 01745 532901 www.ambulance.wales.nhs.uk 

Our ref: 5347 
Your ref: AB/CE/13823 

Date: 21 September 2018 

Ms R Knight 
HM Assistant Coroner 
South Wales Central Area 
The Coroner’s Court, 
Courthouse Street 
Pontypridd 
CF37 1JW 

Dear Ms Knight, 

Re: Richard Thomas Peter Barrett (deceased) 

This  is  a  response  to  the  Regulation  28  Report  to  Prevent  Future  Deaths  that  you 
issued  to  Cardiff  &  Vale  University Health  Board  (the  Health  Board),  the  Minister of 
Health and  the Welsh Ambulance  Services NHS Trust  (the Trust) on  30th  July 2018 
following the conclusion of the inquest for Richard Thomas Peter Barrett. 

The Welsh Government will respond to you separeatley. This is a joint response from 
the Trust and the Health Board. Within your report you asked the Trust and the Health 
Board to consider and address the following specific issues: 

a)  Demand Analysis and its fitness for purpose and b) Provision of adequate 

ambulance and call handler resources in a growing city. 

As described at the Inquest the Trust currently uses previous year’s emergency 
demand  profile,  with  a  percentage  uplift  when  trying  to  predict  the  daily 
emergency demand. 

In  addition  the  Trust’s  Planning  &  Performance  Directorate  since  July  2018 
have    been    working    on    a    project    in    relation    to    Optima    Predict. 

Cadeirydd Dros Dro/Interim Chair: Martin Woodford 
Prif Weithredwraig Dros Dro/Interim Chief Executive:  Patsy Roseblade 
Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg 
The Trust welcomes correspondence in Welsh or English 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Optima  Predict  is  a  powerful  interactive  strategic  planning  solution  for 
Emergency Medical Services (EMS) that provides a platform for effect the Trust 
an in-house capability to undertake work like the Operation Review Demand & 
Capacity Review. 

Optima Predict takes into account key performance indicators (KPIs) such as 
response  times,  vehicle  coverage  and  shift  requirements  and  allows  users to 
quickly build scenarios that make logistical and business sense.  It can be used 
to  estimate  call  volumes,  for  the  coming  year  and  beyond,  test  different 
coverage  and  posting  plans,  test  proposed  roster  changes  and  then  analyse 
their  impact,  enabling  the  Trust  to  select  the  most  effective  option  and  take 
action. 

The project is ongoing and the Trust is currently modelling the plan for Optima 
Predict and the issues that will be selected for analysis. I hope this reassures 
you  that  the  Trust  is  taking  action  to  address  and  further  strengthen  future 
planning by using this software. 

The  use  of  the  software  will  assist  the  Trust  in  planning  the  utilisation  of 
available resources to inform our Integrated Medium Term Plan. 

The Trust has also undertaken the recruitment of  90 additional staff, who are 
undergoing  training  and  will  be  operational  by  December  2018.  Whilst  the 
increase in staff is pan Wales, a proportion of the new staff will be operational 
in the Cardiff and Vale area. This will enable the Trust to increase the number 
of staff available. 

c)  The  process  of  making,  and  timing  of  welfare  calls,  particularly  in 

overdose cases. 

Currently  the  documentation  on  management  of  welfare  calls  is  part  of  the 
Trusts  Resource  Escalation  Action  Plan  (REAP)  and  Demand  Management 
Plan  (DMP)  for  the  Clinical  Contact  Centres.  This  states  that  welfare  calls 
should  be  made  when  Red  calls  are  waiting  more  than  8  minutes  with  no 
resource  allocated,  when  Amber  calls  are  waiting  more  than  20  minutes  with 
no resource allocated, when green calls are waiting more than 30 minutes with 
no  resource  allocated  and  when  Health  Care  Professional  calls  have  had  no 
resource allocated within the agreed timeframe. 

The  welfare  call  is  undertaken  by  an  identified  member  of  Clinical  Contact 
Centre (CCC) staff from either the call taking or dispatch function depending on 
who has the most capacity. The Demand Management Plan identifies that ‘It is 
recognised that delays are often a reflection of demand and as such capacity 
to undertake a robust welfare call procedure is challenging. Every effort should 
be  made  to  facilitate  this  process  to  maintain  good  customer  practice  where 
possible’.  All  callers  are  informed  to  ring  back  if  the  patient’s  condition 
deteriorates. 

If there is no answer on a welfare call the Demand Management Plan instructs 
the incident should be referred to a registered clinician on the clinical desk for 

2 

 
 
 
 
 
 
 
 
 
 a  decision  on  whether  the  response  should  be  upgraded.  At  times  of  high 
demand when incidents are polling waiting for a resource the Clinical Support 
Desk Shift Lead will also review calls or allocate a clinician to review a specific 
category of call. 

Following  this  specific  incident  an  email  was  sent  to  the  Clinicians  on  the 
Clinical  Support  Desk  on  the  15th  May  2018  by  the  CCC  Clinical  Lead.  The 
email identified the importance of attempting to review protocol 23 (overdose) 
calls  when  there  were  delays  in  responding  as  these  may  be  time  critical.   If 
there  was  no  reply  the  clinicians  should  use  their  critical  thinking  skills  to 
determine  how  likely  unconsciousness  or  death  would  be  based  on  what  the 
patient is recorded as having taken and act accordingly. 

The advice of the Clinical Control Centre Technical Manager has been sought 
and she has confirmed that unfortunately currently there is no searchable way 
of identifying if the patient is on their own. The queue also cannot be filtered to 
a specific protocol, however it is possible to view the codes whilst the incident 
is waiting on the Recall Waiting Call queue and as mentioned cases relating to 
overdose will have a code that starts with the number 23. 

d)  Turnaround delays at the major hospitals and the unrealistic target. 

The  Health  Board  and  the  Trust  work  closely  together  to  minimise  delays  in 
hospital handover and ensure patients  receive  the  care they need in  a timely 
manner.  In  common  with  most  hospitals  the  Health  Board  can  experience 
occasions  when  the  number  of  ambulances  arriving  at  the  emergency  unit 
temporarily  exceeds  the  capacity  of  the  unit  to  safely  receive  the  patients, 
leading to a delay in handover from the Trust’s crews. We are very aware that 
these  waits  are  not  only  sub-optimal for  the  patient  on  the  ambulance  at  the 
time  but  can  also  affect  the  ability  of  the  Trust  to  respond  to  patients  in  the 
community.  For  these  reasons  we  endeavour  to  keep  these  delays  to  an 
absolute minimum and closely monitor our performance on an hourly and daily 
basis. 

Over  recent  years  the  Health  Board  has  made  significant  changes  in  its 
unscheduled  care  system,  including  substantial  investment.  These  have 
included:  an  increase  in  the  Emergency  Unit  (EU)  medical  and  nursing 
workforce, the establishment of an Ambulatory Emergency Care (AEC) unit, the 
commissioning of three additional resuscitation bays, an increase in emergency 
theatre  capacity,  an  expansion  of  the  Frail  Older  Person  Assessment  and 
Liaison  (FOPAL)  service,  a  redesign  of  the  Emergency  General  Surgery  and 
Urology  services  to  provide  a  dedicated  consultant  daily,  and  an  increase  in 
critical care capacity. 

In addition the Health Board has worked with its regional partners, including the 
Trust, to redesign the unscheduled care system seeking to reduce the need for 
emergency   conveyance,   attendance   and   admission   and   implementing 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 alternative pathways of care. These have included preventative initiatives with 
the local authorities, support for care homes, a frequent attenders programme, 
investment  and  skill  mix  changes  in  GP  out-of-hours,  the  establishment  of  a 
community  assessment  unit,  the  expansion  of  the  community  resource  team 
(CRT) to seven days/week, and the development of Trust’s pathways aimed at 
reducing  the  number  of  ambulance  conveyances  to  the  emergency  unit 
(including the use of taxis where appropriate). 

During the winter months it is recognised that the demands on the unscheduled 
care system can be significantly higher and more variable than at other periods. 
The  Health  Board  leads  on  the  development  of  a  regional  integrated  winter 
preparedness  plan  for  Cardiff  and  Vale  jointly  produced  by  the  partnership 
organisations: the Health Board, the Trust, Cardiff Council, Vale of Glamorgan 
Council, Cardiff Third Sector Council and Glamorgan Voluntary Services. This 
plan seeks to coordinate the preparations for winter to anticipate and mitigate 
the  impacts  of  winter  pressures  as  best  this  can  be  achieved  within  the 
constraints of the system. 

Throughout the year the staff within the Emergency Unit work closely with Trust 
colleagues  to  respond  dynamically  to  the  operational  demands  and  maintain 
safe  levels  of  care.  Senior  managers  from  both  organisations  meet  on  a 
monthly  basis 
identify 
opportunities for improvement. 

to  address  any  operational 

issues  raised  and 

The  unscheduled  care  system  is  complex,  multi-factorial  and  often  highly 
variable.  In  the  case of  Cardiff  and  Vale  it  operates within  an  environment of 
both  an  ageing  and  a  rapidly  growing  population.  The  impact  of  this  can  be 
seen in the EU data with attendances in 2018 (January-July) up 1.8% on 2017 
and 9% higher than 2015. By contrast ambulance conveyances have actually 
reduced reflecting the positive impact of the work described above and within 
the Trust. 

As described, minimising ambulance handover delays is a particular focus for 
the Health Board and the Trust. Despite a difficult winter period the total number 
of  lost  ambulance  hours  reduced  during  2017/18  by  5%  (prior  to  winter  the 
improvement  was  running  at  20%).  In  recent  months  the  Health  Board  has 
established two-hourly safety and performance huddles in EU to closely monitor 
the status of the unit (including any ambulances waiting outside) and proactively 
respond  to  any  build-up  of  pressures. This  has  contributed  to  continuing  that 
improvement  trend  since  the  end  of  winter,  with  July  2018  having  the fewest 
handover delays of any month for three years. 

The  Trust  also  continues  to  try  and  avoid  admission  of  patients  to  the 
Emergency Department when it is safe to do so. Whilst the following actions do 
not directly affect how long ambulances take to hand over the care of patients 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 when  they arrive  at hospitals, these actions see a  reduction  in  the number of 
patients attending Emergency Departments across Wales and improve the flow 
of patients within the NHS. Please find appended to this response some details 
of these supporting actions. 

e)  Asking  the  police  to  undertake  a  welfare  check  in  an  overdose  case, 
where the patient is alone and an ambulance is likely to be hours away. 

We have a memorandum of understanding with the Police which does specify 
circumstances in which the Trust should contact the Police. Welfare checks are 
not included within that document. The Trust does meet with the Police as part 
of the joint emergency services network. The Trust will raise this issue with the 
Police  at  these  joint  meetings  and  seek  an  increase  to  the  specific 
circumstances to include overdose cases. We will write to you further once that 
meeting has taken place and update in relation to the matter. 

It may not be possible for the Trust’s systems to identify cases where a patient 
is  alone  and  the  request  may  need  to  be  made  in  all  cases,  rather  than  just 
situations where the patient is on their own. 

In summary we would like to confirm that the Trust has and will continue to action the 
following: 

  CCC Clinical Leads have been reminded that Protocol 23 cases should be dealt 

with in a timely manner. 

  The Trust will approach the Police with a view to formally extend the MOU to 

include overdose cases. 

  Expansion of the clinical desks. 
  Rolling out the APP model across Wales 
 

Implementation  of  Level  1  response  to  people  who  have  fallen  and  are  not 
injured. 

We  would  like  to  reassure  you  that  the Welsh  Ambulance  Services  NHS  Trust  and 
Cardiff  and  Vale  University  Health  Board  continue  to  work  together  to  drive  the 
improvements  and  learning  forward  that  we  had  commenced  last  autumn  and  we 
continue  to  strengthen the out of hospital  alternative  pathways  to  improve  efficiency 
and effectiveness of care for our patients and make best use of our resource. 

We hope that we have been able to assure you that we continue to work collaboratively 
to  improve  services  together  and  that  actions  taken  to  date  have  had  an  impact  in 
relation to all of the areas identified within this Regulation 28 Report, namely improving 
our  response  to  people  in  the  community,  avoiding  patients  being  conveyed  by 
ambulance  to  the  Emergency  Departments,  increasing  the  capacity  of  appropriate 
resources and assisting in patient flow. 

We would like to extend the offer to meet with you to discuss our response in more 
detail and to provide you with assurance of our commitment to the continuous improve 
our service provision. 

5 

 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Patsy Roseblade 
Chief Executive (interim) 
Welsh Ambulance Services 
NHS Trust 

Len Richards 
Chief Executive 
Cardiff and Vale 
University Health Board 

Enc: WAST Supporting Information TRPB 

6

Professor Chris Jones 
Dirprwy Brif Swyddog Meddygol  
Deputy Chief Medical Officer 

Ms Rachel Knight  
HM Assistant Coroner 
South Wales Central Area 

September 2018 

Dear Ms Knight, 

Regulation 28 Report to Prevent Future Deaths – Richard Thomas Peter Barrett  

Thank you for your letter enclosing the above Regulation 28 report following your investigation 
into the death of Richard Thomas Peter Barrett. I’m responding on behalf Vaughan Gething 
Cabinet Secretary for Health and Social Services. 

The  Welsh  Government  expects  the  Welsh  Ambulance  Services  NHS  Trust  (WAST)  to  plan 
and  deliver  a  safe  and  timely  service  to  the  people  of  Wales,  based  on  an  assessment  of 
demand,  ensuring  there  is  sufficient  staffing  and  resource  cover  in  its  clinical  contact  centres 
and in the community to meet demand, and to flex capacity at times of increased pressure.  

WAST has reported that at times of increased demand, capacity to undertake welfare calls is 
reduced and it is currently considering options to increase capacity on its clinical support desk 
which provides support and advice over the telephone, as well as opportunities for third sector 
organisations and other agencies (e.g. Police, Fire and Rescue Services) to support the 
delivery of welfare checks, particularly for patients who have experienced a delayed response. 

In April of this year, the Cabinet Secretary for Health and Social Services commissioned the 
Chief Ambulance Services Commissioner to conduct a clinically-led review of the ‘Amber’ 
category, which includes serious, but not immediately life-threatening calls and accounts for 
around 65% of call volume to the Welsh ambulance service.  The review is being undertaken 
alongside ongoing work to improve ambulance responsiveness, clinical outcomes and patient 
experience in order to make sure patients continue to get the most appropriate and best level of 
care and treatment for their needs.  It is due to be completed at the end of this month and the 
Cabinet Secretary will be making a statement to inform Assembly Members on how its findings 
and recommendations will be taken forward in October. 

A  key  part  of  the  review  is  an  examination  of  patient  risk  across  the  pre-hospital  patient 
pathway.  This includes analysis of patient-level linked information across the pathway as well 
as serious incidents and Coroners’ reports to identify opportunities for learning to be applied to 
inform the review’s recommendations. 

Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ 

Ffon/Tel:  029 2082 3911   

Ebost/Email:PSChiefMedicalOfficer@wales.gsi.gov.uk                         

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  review  is  also  looking  at  expectations  and  experiences  of  the  public,  staff  and  the  wider 
service  around  ambulance  response.    This  will  include  the  extent  to  which  members  of  the 
public  are  supported  and  kept  informed  when  making  a  999  call.    In  this  respect,  the  review 
may deem it necessary to make recommendations around continuity of care through increased 
welfare checks for all relevant calls and other options to reduce anxiety of those waiting for an 
ambulance to arrive. 

The  Welsh  Government  recognises  the  challenge  caused  by  lengthy  handover  delays  at 
emergency departments, which we know can impact not only on patient experience, but also on 
the ability of the ambulance service to respond to subsequent urgent calls in the community.  

We  expect  health  boards  to  monitor  all  patients,  especially  those  with  time-critical  and  acute 
conditions or injuries to ensure they are handed over to the care of specialist staff as soon as 
possible, in order to improve patient outcomes and  manage the associated risk.   The Cabinet 
Secretary  has  also  been  clear  with  health  board  chief  executives  that  they  must  take 
responsibility  to  reduce  and  eradicate  patient  handover  delays  by  working  with  the  Welsh 
ambulance  service  and  partner  organisations  to  improve  patient  flow  through  hospitals  and 
receive  patients  from  ambulance  crews  in  a  safe  and  timely  manner.    In  addition  they  must 
explore alternative pathways and be able to divert demand to other unscheduled care services 
to reduce pressure at emergency departments during busy periods. 

It  should  be  noted  that  there  is  no  time-based  target  for  the  handover  of  patients  from 
ambulance crews to emergency department staff.  However, the Welsh Health Circular on NHS 
Wales Hospital Handover Guidance, published in May 2016, sets out good practice for patient 
handover, including an expectation for patients to be handed over within 15 minutes.  Officials 
continue  to  monitor  patient  handover  delays  closely  on  a  daily  basis  and  challenge  health 
boards where appropriate. 

I do assure you that Welsh Government will keep this case and the learning that arises under 
ongoing review. 

Yours sincerely 

PROFESSOR CHRIS JONES