Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0267, written 7 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Aug 2018 |
|---|---|
| Reference | 2018-0267 |
| Deceased | Steven Welch |
| Coroner | Sarah-Jane Richard |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Mr. Steven John Welch who died on 29 December 2017 at Southmead Hospital Bristol. THIS REPORT IS BEING SENT TO: His Honour Judge Mark Lucraft QC, Chief Coroner for England and Wales; Mr. Jason Killens, Chief Executive Welsh Ambulance Service Trust; Ms. Allison Williams, Chief Executive, Cwm Taf University Health Board; Mr. Kamal Asaad, Medical Director, Cwm Taf University Health Board; Mr. Len Richards, Chief Executive, Cardiff and Vale University Local Health Board; Dr. Graham Shortland, Medical Director, Cardiff and Vale University Local Health Board; . Co Director of Legal & Risk Service NWSSP; and ee CORONER lam Sarah-Jane Richards, Assistant Coroner, for the coroner area of South Wales Central CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 25" January, 2018 an investigation was commenced into the death of Mr. Steven John Welch aged 45 years. The investigation concluded at the end of the inquest on the 20" July 2018 having identified several omissions in the healthcare provided to the deceased prior to his transfer ‘out of area’ to Southmead Hospital, Bristol, England some of which have a relevance to Regulation 28 and prevention of future deaths. The medical cause of death was 1a - Pulmonary embolism; 1b - Deep vein thrombosis; and 1c Subarachnoid haemorrhage due to ruptured cerebral artery aneurysm. The conclusion of the inquest was a narrative determination. CIRCUMSTANCES OF THE DEATH Mr. Steven Welch reported having suffered a fall several days prior to being found on 26 December 2017, in a ‘rousable’ but immobile condition at home by his father, The Welsh Ambulance Service Team (WAST) received 999 calls from Mr. Graeme Welch at 12.09, 12.47 and 13.10 hrs on 26 December 2017. A separate Regulation 28 has been provided in respect of delays in transferring Mr. Welch from home to the Royal Gwent Hospital (RGH) on 26 December and again when transferring Mr. Welch from the RGH to University Hospital of Wales, Cardiff (UHW) on 27 December 2017. During this time, Steven Welch's condition deteriorated. Mr. Welch was admitted to the Accident & Emergency Department RGH at 15.18 hrs whereupon he was triaged as a collapsed aduit with a history of sustaining a head injury a few days previously, unconsciousness and, as a yellow category, should have been seen by a clinician within an hour according to Manchester triage guidelines. This did not occur. Witness evidence at inquest reported high A&E demand at the RGH throughout 26 December, 2017 with most of Mr. Welch's care being nurse practitioner led. It was a nurse practitioner who at 18.45 hrs undertook an assessment of Mr. Welch as he was laying on a trolley. This was 3 hrs 30 mins after admission. He was noted to have a reduced level of consciousness (Glasgow Coma Score of 11/15 from 15/15 on admission) and he was not responding. A CT scan of head and x-ray of ankle and foot were requested. He was found to have suffered a fracture of his right fibula which was treated by the trauma team with a back-slab. At 20.00 hrs a CT scan of head was undertaken. The RGH does not support a neurosurgical team instead UHW Cardiff is the tertiary neurosurgical centre for the RGH. Mr. Welch's CT scans were reviewed by the neurosurgical team at UHW and a subarachnoid haemorrhage was diagnosed. A CT angiogram was requested. Mr. Welch should have been transferred immediately to Cardiff for monitoring of intracranial pressure, interventionist radiology and vascular coiling to reduce the risk of a further bleed. However, for reasons unknown to the inquest, UHW had received resignations of its interventionist radiologists and in consequence, all patients requiring this form of treatment were sent out of area to Southmead Hospital, Bristol. The neurosurgical team at Cardiff advised that in the absence of UHW being able to provide the specialist radiology required, RGH should arrange admission directly with Southmead Hospital. The neurosurgery team at Southmead Hospital agreed in principle to accept Mr. Welch subject to the review of the CT scans undertaken at the RGH. The inquest heard that commissioning of software required for transfer of radiology images is Wales based, thus while images could be transferred between Welsh hospitals for neurosurgical review they could not be sent across the border for review by non-Welsh hospitals. This is a serious commissioning omission as neuroimaging transfer between hospitals nationally and internationally has been available for approximately 20 years. Southmead Hospital reasonably insisted upon receipt and review of neuro-radiology before accepting Mr. Welch as a patient. Had RGH had electronic transfer technology to ‘out of Wales’ hospitals, Mr. Welch’s neuro-images could have been reviewed within minutes of being sent electronically to Bristol. Had this been the case, Mr. Welch could have been transferred to Southmead Hospital on the evening of 26 December 2017 when vascular coiling remained an option. Instead, the CT images were to be printed and faxed to Southmead for review. However the only printer available had run out of ink and there were no spare ink cartridges available. Eventually, the images were sent electronically to Prince Charles Hospital, Merthyr Tydfil where they were printed and dispatched by taxi to Southmead Hospital. Throughout this delay, Mr. Welch's condition further deteriorated. The A&E nurse practitioner responsible for Mr. Welch at the RGH repeatedly requested Mr. Welch's transfer to UHW which unlike the RGH, supported a neuro-surgical team which could monitor intracranial pressure and undertake emergency surgical intervention if required. At 05.00 on 27 December 2017, Mr. Welch was admitted to UHW where he was diagnosed as suffering from hydrocephalus, subarachnoid haemorrhage, anterior communicating artery aneurysm and a fluctuating GCS of 10-14/15. He was referred to the neurosurgical team for emergency external ventricular drain insertion and continuous cerebrospinal fluid drainage in order to reduce cranial pressure. He suffered two seizures. He was intubated by the anaesthetic team for safe transfer to Southmead Hospital at 4pm on 27 December 2017 for further endovascular management. Upon arrival at Southmead Hospital Mr. Welch was considered too unwell to undergo prophylactic vascular coiling. His cardiac function was causing great risk to his life. He had received a pulmonary embolism risk assessment on 27 December 2017 and provided anti-embolism stockings. In spite of supportive treatment Mr. Welch continued to deteriorate and died. Post mortem findings confirmed that Mr. Welch had not suffered a further cerebral bleed and that the cause of death was a pulmonary embolism most likely originating from a deep vein thrombosis of the left leg. It is accepted that the delays in providing neurosurgery at UHW and the provision of CT images for review by Southmead Hospital did not cause the death of Mr. Welch and the extent to which they contributed to the death, if any, is unclear. However, rapid diagnosis and treatment of cerebral bleeds and reduction of increased cranial pressure invariably increases the likelihood of survival and for this reason, the Cwm Taff and Cardiff and Vale University Local Health Boards, are invited through this Regulation 28 to address the following concerns arising from Mr. Steven Welch's treatment on 26/27 December prior to being transferred out of area to Southmead Hospital: i) Failure by the RGH to provide a timely assessment upon A&E admission including head CT scans of a man who was known to have suffered a head injury; ii) Knowing that neurosurgical cover is provided to RGH patients by UWH why UHW delayed admitting Mr. Welch and performing essential neuro-surgery when it was always the case that the Southmead neurosurgical team could have denied the admission of Mr. Welch to their facilities upon reviewing his radiology; ii) Failure by Cwm Taff Health Board through its tertiary UHW (Cardiff and Vale University Local Health Board) to have access to interventionist radiologists within Wales at the time (and one only at the time of inquest) thereby having to send patients who have suffered cerebral bleeds and who require interventionist radiology, out of area for treatment; iv) Failure by Cwm Taff and Cardiff and Vale University Local Health Boards to have software in place in 2017 permissive of radiological review by hospitals and specialist centres out of Wales; and v) Related to iv) above, in the absence of an ability to transfer radiological images electronically from Cwm Taf Health Board and Cardiff and Vale University Local Health Board hospitals to hospitals and specialist centres out of Wales, why the RGH did not ensure a printer was always maintained to print and fax images for external review and for a back-up to be available at all times in case of technical failure. No patient transfer should be delayed and life put at risk as a result of a printer not having ink in its cartridge. vi) Whether or not concerns rightly raised by Advanced Nurse Practitioner, (RGH) and Consultant in Emergency Medicine Te-hospital Emergency Medicine through an incident report to UHW have been acted upon and feedback provided in each case. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch's death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital; iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe the Royal Glamorgan Hospital and its Health Board and the University Hospital of Wales and its Health Board, have the power to take such action in the areas of: i) ensuring its A&E Department is appropriately staffed and facilitated at all times including statutory holidays; ii) that all Cwm Taf Health Board and Cardiff and Vale University Local Health Board hospitals have the benefit of software which enables radiology to be sent to hospitals and specialist centres out of Wales for review; iii) that as the University Hospital of Wales and the teaching hospital for Cardiff - the capital city of Wales - interventionist radiology is restored as an area of specialism at the level required for its catchment population; and iv) in the event the Cardiff and Vale University Local Health Board is unable to provide facilities to hospitals run by other Health Boards (as was the case here) that those hospitals are notified of such unavailability (whether temporary or permanent) and alternative access to specialist healthcare treatment is advised. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 October 2018. |, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of this report to the following: His Honour Judge Mark Lucraft QC, Chief Coroner for England and Wales; Mr. Jason Killens, Chief Executive Welsh Ambulance Service Trust; Ms. Allison Williams, Chief Executive Cwm Taf University Health Board; Mr. Kamal Asaad, Medical Director, Cwm Taf University Health Board; Mr. Len Richards, Chief Executive, Cardiff and Vale University Local Health Board; Dr. Graham Shortland, Medical Director, Cardiff and Vale University Local Health Board; , Director of Legal & Risk Service NWSSP; an ather of the deceased. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dr. Sarah-Jane Richards HM Assistant Coroner
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Partneriaeth Cydwasanaethau Gwasanaethau Oyfreithiol a Risg law X97 we WALES | Shared Services Partnership Legal and Risk Services Ffén/Phone: 039 3090 3769 Dr $ J Richards Ebost/Email: HM Assistant Coroner Eich cyf/Your ref: South Wales Central Area Ein cyf/Our ref qytoaisget wie The Coroner’s Court, Courthouse Street Pontypridd CF37 1JW Dyddiad/Date: 9) gctober 2018 Mr Steven John Welch (deceased) This letter is in response to the two Regulation 28 Reports to Prevent Future Deaths that you issued to me on 7 August 2018 following the conclusion of the inquest into the death of the late Mr Steven John Welch at which one of my staff, MM represented both th bulance Services Trust and Cwm Taf University Health Board. Following the inquest, wrote by email to to provide him with contact details for the three health bodies involved in the care of his son, to enable him to ask further questions directly if he wished. My role is as Director of the NHS Wales Shared Services Partnership Legal and Risk Services and the Welsh Risk Pool Service. Solicitors employed by Legal and Risk Services provide advice and support to all health bodies in Wales across a range of legal issues including clinical negligence and those relating to inquests. When requested by a health body, we assist in the investigation of the circumstances of a death; provide support in respect of the taking of witness statements and advise of the likely issues which will be the focus of a Coroner’s attention. During the course of the conduct of clinical negligence claims, including those where there has been or will be an inquest, it is common for us to recommend obtaining an independent expert opinion to identify those issues which may represent a standard of care which falls below that which is acceptable: on occasion, that expert identifies a real cause for concern which may affect patient safety. In those circumstances the content of the report is drawn to those senior clinical directors in the health body who are in a position to review the current provision of care and policies and who will be able to make urgent changes where necessary. We are not responsible for ensuring those changes are made and nor do we seek to influence clinical decisions. That is not to say that I do not recognise the importance of Cyfarwyddwr / Director Anne-Louise Ferguson 4th Floor, Companies Hause *e = i Crown Way Mae Gwasanaethau Cyfrelthial a Risg yn is-adran ofewn Partneriaeth ronnie eee Boao ‘yowasanaethau ymru . Legal and Risk Services ts a + Fax: 029 2090 4146 division of the NHS Wales | o Le “Eel DX: 124592 Cardiff (Co. House} Shared Service Partnership } j if Legat Practice Quality Mark. Lee «| Law Societv the work that we do to support the clinical teams to reduce harm to patients by our careful review of the internal and the independent reports obtained into care complained of. The Welsh Risk Pool Service has two primary functions: the first is to reimburse health bodies which have paid compensation and costs in respect of a clinical negligence or other personal injury claim made against it. In order for the advisory board of WRPS to approve reimbursement, a careful scrutiny of papers submitted to provide evidence of the lessons learned from the events leading to the claim is undertaken, notwithstanding that these events may have been some years before. Insufficient or unsubstantiated submissions are rejected and reimbursement deferred or even, in extreme cases refused, until clear, auditable action plans are produced. The second function is to provide support and assistance to health bodies in the provision of training to improve risk management and clinical standards. Staff spend lengthy periods undertaking reviews into issues which present as a trend in the claims reimbursement process, for example, review into the incidence and early identification of pressure sores. The Head of Safely and Leaming of WRP is invited by health bodies to offer advice and assistance to clinical departments to improve patient outcomes; however we have no mandate to introduce any reforms or improvements ourselves. The issue of the transfer of radiology between health bodies both within Wales and across the border will be scheduled into the current work programme. I believe that the legal and support services we provide to health bodies in Wales is proactive in helping them recognise and respond to clinical risks which we identify in claims and our investigations at their request but we do not have a place on their boards and have no influence or contro] to bring about service change which must be a matter for the boards themselves. I should be happy to meet with you to discuss my role and that of my team should that be of assistance. Yours sincerely Febery = Legal & Risk Services
Ymddiriedolaeth GIG G Bwrdd lechyd Prifysgo! Gwasdscthau AmBiwlans Cymru L ~ G IG L ~ ow Caerdydd a'r Fro Welsh Ambul: 5 Cardiff and Vale NHS Trust eee eS Ov N HS \ 7 HS University Health Board Pencadlys yr Ymddiriedolaeth, Safle H M Stanley, Llanelwy, Sir Ddinbych LL17 ORS Trust Headquarters, H M Stanley Site, St Asaph, Denbighshire LL17 ORS Tel/Ffén 01745 532900 Fax/Ffacs 01745 532901 www.ambulance.wales.nhs.uk Our ref: JKO1/tf/5233 2"4 October 2018 Dr SJ Richards HM Assistant Coroner South Wales Central Area The Coroner's Court Courthouse Street Pontypridd CF37 1JW Dear Dr Richards Re: Mr Steven John Welch (deceased) This is the response of the Welsh Ambulance Services NHS Trust to the Regulation 28 Report to Prevent Future Deaths that you issued to ourselves (the Trust) on 7 August 2018 following the conclusion of the inquest the late Mr Steven John Welch. Within your report you asked the Trust to consider and address the following specific issues: Training needs of 999 emergency call telephonists for medical assistance. | can confirm that the call handlers, known as Emergency Medical Dispatchers (EMDs), training schedule was last reviewed prior to the last induction of new recruits in July 2018. All trainees have to be signed off as competent before they are allowed to go live within the operational service. The auditors within the clinical contact centre act as mentors to the new EMDs and are experts in the level of competency required to take 999 calls. There is another group of staff who are responsible for allocating ambulance responses to incidents, these are called Allocators who dispatch the ambulance via the Computer Aided Dispatch (CAD) system. They can elecironically send a message Cadeirydd Dros Dro/interim Chair: Martin Woodford Prif Weithredwraig /Chief Executive: Jason Killens Mae'r Ymddiriedoteeth yn croesawu gohebloeth yn y Gymraeg neu’r Soesneg The Trust welcomes correspondence in Welsh or English to the vehicles to allocate them to an incident. The Allocators are supported by Dispatchers who assist with meal break management, vehicle breakdowns and radio communications etc. We do not expect Allocators/Dispatchers to maintain their call taking skills unless they are undertaking regular calls. If for any reason an EMD has not been call taking due to prolonged sickness or being seconded to a different role they would be expected to undertake a refresher course and have their competency reassessed prior to commencing live independent call taking. The purpose of the Medical Priority Dispatch System (MPDS) Quality Assurance and Improvement is to ensure staff adhere to a standardised practice and procedure as defined by the international Academies of Emergency Dispatch® (IAED™) when using their prioritisation software product. The quality improvement audit process is intended to support staff and identify learning needs as well as recognising performance strengths. Therefore, auditing calls is a vital function to ensure these standards are maintained. If any skills gaps are identified the EMD will receive extra coaching, be supported with a coaching plan and capability may be considered if they fail to reach an acceptable standard following appropriate support. EMDs are required to undertake recertification every 2 years, sit an exam and demonstrate they have undertaken 24 hours of Continuing Dispatch Education (CDE) in that time. With regard to the use of the breathing tool the Trust is and has been working with the International Academy of Emergency Dispatch (IAED) to try and improve the assessment of breathing over the phone. It is well recognised that this is very difficult to assess with callers and to aid EMDs the Breathing Verification tool has been developed. It is very clear in MPDS guidelines that if there is uncertainty about whether the patient is breathing they should act as if the patient is not breathing. If the patient is unconscious and is reported as breathing abnormally the caller is asked to check if they can feel or hear breathing. If the answer is “no”, then Cardio Pulmonary Resuscitation is started. If the answer is “yes”, the breathing will be further evaluated using the Breathing Verification tool. The caller is asked to indicate every time the patient takes a breath to ensure the patient is breathing effectively. The auditors monitor the use of the breathing tool to ensure it is being used correctly. Whilst the Trust does not propose to change its systems following the receipt of the Regulation 28 report, | hope this reassures you that the Trust does have in place systems for considering call takers initial training needs, as well as monitoring their ongoing performance, with built in occasions to identify and act on remedial training needs. The complexity of the emergency call ranking system (MPDS) for users and whether or not this may contribute to errors occurring. MPDS has been designed to generate a code in response to an emergency call. As | am sure you will appreciate given the vast number of possible reasons for making a clinical call and the clinical conditions that can exists, MPDS can generate 1,933 different codes. These codes are then matched to the 5 different categories of response (Red, Ambers and Greens) in the Clinical Response Model. MPDS has been designed to be screen driven thus making it easier for the EMD to use. It follows a ‘flow chart’ type system with one answer leading to the next question. This depends on the EMDs correctly recording into the system the responses received from the caller. In response to the Regulation 28 received from yourself we have undertaken a review of the calls taken for the first 6 months of the year to explore if there is any evidence to support the supposition that MPDS is too complex for call handlers to use effectively. Of the calls audited only 7% of calls were non-compliant. A total of 85% were of high compliance and in order to get a recorded result of high compliance the call taker has to have scored a perfect 100%. Number of Cases High Compliance || 85% 2990 Compliant [ 6% 203 Partial Compliiance 2% 60 [ 7% 247 Percent Low Compliance Non-Compliant Totals 100% 3515 From this data it can be concluded that the EMDs generally do use the MPDS software correctly. The audit data was examined to identify if there was any particular aspect of the call taking that the EMDs had difficulty with. No one aspect of call taking stood out as presenting an issue other than the delivery of Dispatch Life Support (DLS) instructions. Dispatch Life Support includes all instructions given during the call, this does not affect the category of the call. The DLS deviations relate to a moderate deviation. Moderate deviations are those deviations from expected performance considered to be incongruent with the desired function and design of the protocol without a direct impact on safety. These deviations can affect the most appropriate instructions provided, but they are not expected to have a direct negative impact on the patient/victim or scene outcome. On each of the critical deviations 97% or more of the times the calls were managed correctly. A critical deviation are those deviations from expected performance that not only fail to meet the minimum standard of practice but also pose a substantial risk to the caller or patient/victim or that impact responder safety. Examples of critical deviation can include the address not being verified correctly, even if the correct address was given, failure to choose the correct chief complaint, however this might not affect the final categorisation. So although they will be marked as critical it does not always follow that the patient came to harm. Having reviewed this evidence the Trust does not believe the EMDs find MPDS too complex to use. The Trust will continue to monitor the EMD's performance using MPDS and continue to work to improve call takers performance. Percentage of Deviations Moderate Si —=————— SS The Trust is an MPDS Centre of Excellence, one of only 250 such centres worldwide. This is from a pool of over 2500 using the system. Annually, MPDS is used in the prioritisation of 65 million Emergency Medical calls worldwide and has been shown to be a safe system. The failure to predict accurately emergency demand over a public holiday thereby not having sufficient resources at hand or in reserve. As described at the Inquest the Trust currently uses the previous year’s emergency demand profile, with a percentage uplift when trying to predict the daily emergency demand. The Trust is aware of the need to consider changes to the demographics in Wales, both current and predicted, and as such the Trust's Planning & Performance Directorate, since July 2018, have been working on a project in relation to Optima Predict. Optima Predict is a powerful interactive strategic planning solution for Emergency Medical Services (EMS) that provides a platform to undertake Operational Demand & Capacity Review. Optima Predict takes into account key performance indicators (KPls) 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. | 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 Cwm Taf area. This will enable the Trust to increase the number of staff available to it and the number of staff that can be considered as being available “in reserve", allhough we are obviously restricted by the number of vehicles available and available budgets. The impact of lengthy patient handover delay times between emergency ambulance and recipient hospitals, upon the delivery of an effective emergency service. The Cwm Taf University Health Board (the Heaith Board) and the Trust already work closely together to minimise delays in hospital handover and ensure patients receive the care they need in a timely manner. 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. It should be noted that Cwm Taf University Health Board is commended for their focus on flow improvement model that has achieved the least lost hours for hospital handover from the Trust in NHS Wales. Whilst our colleagues at the Health Board will share with you the actions they are taking to continue to minimise handover delays, in response to the Regulation 28 report you issued separately to them, | would like to assure you that the Trust also continues to try and avoid conveyance of patients to the Emergency Departments 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 when they arrive at hospitals, these actions see a reduction in the number of patients being conveyed to Emergency Departments across Wales and improve the flow of patients within the NHS. Please find appended to this response further details of these supporting actions. The Trust has developed robust winter planning actions that will support the requirements of this Regulation 28 report received from you. We would like to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board continue to work together to drive the improvements and learning forward that we commenced last year 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. In conclusion: We hope that we have been able to assure you that as a result of the Regulation 28 the Trust: e Has in place robust systems for the training of call taking staff and systems for the continued monitoring. e Has undertaken a review of errors made by call takers in the last 6 months and the findings provide assurance that the complexity of MPDS is not contributing to the errors made. e Will be using the Optima Predict software to assist the Trust in more accurate predictions in relation to emergency demand and resource deployment. e Continues to work collaboratively with Cwm Taf University Health Board to further reduce patients being conveyed by ambulance to the Emergency Units, 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 learning and the continuous quality improvement our service provision. Yours sincerely Jason Killens Chief Executive
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