Diane Greenslade

f g G IG Bwrdd lechyd Prifysgol
KE > Aneurin Bevan
Ov N HS University Health Board

Our Ref: JP/CB/Ib Direct Line: 01633 435958 30 January 2019

Private & Confidential

Ms Wendy Ann James

Acting Senior Coroner

Coroner’s Office

Victoria Chambers 0 1 FEB 2019
11 Clytha Park Road

NEWPORT NP20 4PB

Dear Mrs James
Re: Diane Greenslade (deceased)

I write further to the receipt of the Regulation 28 report in respect of the
inquest heard into the death of the above named person. We were
extremely saddened to hear the details of this case.

The ability to release ambulance crews in order to respond to community
calls is of paramount importance to Aneurin Bevan University Health Board
(ABUHB) and we are working closely with our Welsh Ambulance Services
Trust (WAST) colleagues ts.improve handover delays.

Ambulance services are measured on the time it takes from receiving a 999
call to a vehicle arriving at the patient's location. Life-threatening and
emergency calls, under the current standards, 65% should be responded to
in eight minutes.

In December 2017, ABUHB region achieved 63% against this target, which
we recognise is unacceptable. However, with the recent work that has been
introduced, this response improved to 71% in December 2018.

Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board
Pencadlys, Headquarters

Ysbyty Sant Cadog St Cadoc’s Hospital

Ffordd Y Lodj Lodge Road

Caerllion Caerleon

Casnewydd Newport

De Cymru NP1i8 3XQ South Wales NP18 3XQ

Ffén: 01633 436700 Tel No: 01633 436700

E-bost: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk

CR 7 GIG
tek! Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredo!l Bwrdd Iechyd Lleo} Prifysgol Aneurin Bevan

Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board

- Ms Wendy James -2- 25 January 2019

As a Health Board, we have reviewed and implemented a number of key
processes which should, in turn improve the timeliness of releasing crews at
the hospital. The Health Board has identified escalation protocols which are
used to guide staff within the Emergency Department (ED) in the operational
procedures for receiving and offloading ambulances. These include
escalation when 3 or more crews are delayed for greater than 30 minutes
and limited capacity exists within the hospital to off load them.

At this stage, the nurse in charge of ED will transfer stable patients from the
majors department to the minors department to create capacity for crews to
bring their patients into the department. This is then a trigger to the site
manager to move patients from ED to any available bed capacity with
immediate effect, or to pre-emptively move towards where there are any
upcoming discharges.

The Health Board has a Full Capacity Protocol which lists a number of
objectives to guide staff to trigger a list of actions, with the overall objective,
to secure and maintain the safety of patients and staff within the ED and
Assessment Units. This is to allow patient moves which facilitate the
immediate handover of ambulances.

The Health Board also has a Red Release Protocol for response to WAST, for
when a crew is required to attend a ‘red’ call in the community. The
identification of a ‘red release’ bed is discussed and agreed at: each
operational site meeting and a patient is identified as the urgent next move
from ED, should the need to respond to a red release is called.

There are times when our Emergency Departments do struggle to offload
ambulances back into the community. We try to make provision at these
times. One of these is during the pressures associated with winter.

The Health Board has a Winter Resilience plan which is designed to manage
the peaks of demand and capacity through the winter period when services
are under significant pressure. The plan was developed with stakeholders
and partners to ensure actions and initiatives described within the plan are
shared, agreed and delivered in partnership. The plan is monitored by all
stakeholders, including WAST, on a weekly basis and also reviewed and
monitored by the Health Board’s Executive Team each week. There are
several initiatives included in the plan which support the timely release of
ambulances at the hospital. For example, we have practitioners reviewing
the WAST calls waiting to attend the hospital to ensure patients are treated
in the most appropriate setting. We will shortly be implementing clinical call
handlers assessing GP calls for admission to hospital. We have additional
doctors in the Emergency Department and on our Assessment Units to
ensure more timely assessment of patients, and we have opened additional
capacity in order to meet the predicted demand. There are several other
initiatives to support the winter pressures to reduce demand, and improve
our flow in order to release ambulances,

Ms Wendy James, -3- 25 January. 2019

I appreciate that the handover delays was crucial in Mrs Greenslade’s case
and were extremely saddened to hear that this was found to be the case. I
do hope that this information gives the assurance that we, as a Health Board
are focussed on the patient experience and actively working in partnership
to reduce ambulance delays in our Emergency Departments and Assessment

Units.

Yours sincerely

Justice Rages

Judith Paget
Chief Executive/Prif Weithredwr

Ymddiriedolaeth GIG
G IG Gwasanaethau Ambiwlans Cymru

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\AL/ NHS | weish ambutance Services

wactes | NHS Trust

Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol
Regional Ambulance Headquarters and Clinical Contact Centre
TY Vantage Point / Vantage Point House, TY Coch Way, Cwmbran NP44 7HF
Tel/Ff6n 01633 626262 Fax/Ffacs 01633 626299

www.ambulance.wales.nhs.uk
Sam Dulance.wales.nhs.uk
CHAIR AND CHIEF EXECUTIVE’S OFFICE
= EE EAECUTIVE’S OFFICE

Eich CyffYour Ref: 5152
Ein Cyf/Our Ref: JK/5152/DR

12 February 2019 / 4 FEp 201
9

Ms W A James

Acting Senior Coroner for Gwent
Coroner’s Office

Victoria Chambers

11 Clytha Park Road

Newport

South Wales

NP20 4PB

Dear Ms James,
Re: Regulation 28 relating to Inquest of Diane Greenslade

| am writing in response to the Regulation 28 Report to Prevent Future Deaths, issued
to the Welsh Ambulance Services NHS Trust (the Trust) on 21st December 2018. This
was issued following the conclusion of the inquest for Mrs Diane Greenslade,

The Trust acknowledges the concerns you have raised in the Regulation 28 Report.
The supporting information, accompanying this letter, highlights the strategic and
operational quality improvements in patient safety that have been completed or are
underway. These are aimed at preventing harm by improving those areas of our
Service identified within your Report.

The attached action plan identifies initiatives that the Trust has implemented, and new
actions, which we continue to work on. The initiatives are designed to improve our
adherence to existing policies, our collaborative working with other emergency
services and our staff resourcing, both operationally and within the Clinical Contact
Centres (CCC). These include:

Cadelrydd Dros Dro/Chair (Interim): Martin Woodford

Prif Weithredwr/Chief Executive: Jason Killens

Mae'r Yddiriedoloeth yn croesawu gohebiaeth yn y Gymraeg neu'r Saesnag
The Trust welcomes comespondence in Welsh or English

¢ Training of relevant Clinical Contact Centre staff

e Recruitment of clinicians within the Clinical Contact Centre

¢ Aligning production against demand both locally and time of day. This means
ensuring we have the right levels of staff availability to meet the demand with
which we are faced

e Reducing the duration of handover to Clear i.e. the time it takes for our staff to
become available following the handover of a patient to another care provider,
generally hospital staff

° Introducing safe alternatives to responding to scene, where this is appropriate

e Reducing conveyance where safe and appropriate, and providing care in the
patient’s home utilising advanced practitioners

¢ Arreduction in sickness absence

In addition to the accompanying action plan, the Trust continues with other quality
improvement initiatives designed to safely release resources to respond to patients in
greatest need. This includes the introduction of our Falls Framework and increasing
the scope of practice for our Community First Responders. | would like to share with
you some details of the Trust’s Falls Framework and the recent development of a more
structured response to people who have fallen in the community, as it is relevant to
the circumstances surrounding the fall that Mrs Greenslade sadly experienced.

Falls Framework and Falis Response Model

During the third quarter of 2018 — 19, the Trust, working in partnership with St John
Ambulance Cymru Wales, has implemented the role of the Falls Assistant across five
health boards:

e Aneurin Bevan University Health Board

e Abertawe Bro Morgannwg University Health Board
¢ Cwm Taf University Health Board

¢ Cardiff & Vale University Health Board

¢ Hywel Dda University Health Board

Level 1: Falls Assistant Role

The Falls Assistants provide an initial response to safely lift patients where there are
No injuries, or a minor injury, as a result of a fall. The Falls Assistants will be supported
in their assessment of the patient by a paramedic or nurse working on the Clinical
Support Desk in our CCC, who will offer clinical advice and support.

A Falls Assistant can be a member of Trust staff from our Urgent Care Service, a
voluntary Community First Responder, or in partnership with other agencies,
employed by another organisation such as St John Cymru Wales or the health board.
There are now seven Falls Assistant schemes working across Wales providing support

across five health board areas. During October- December 2018 the teams attended
771 patients across Wales. In North Wales we have developed a model with our
Community First Responders where we have 10 teams working across the region.

Level 2: Possible Injury Fall/Complexity- Falls Response Service

A Level 2 falls response is required either where it is unclear if there is an injury or not,
or where the person has co-morbidities or complex needs. A level 2 response is where
a multi-disciplinary team can undertake a comprehensive assessment of the person
in their own home and implement an appropriate care plan according to their individual
need.

Currenily, within the Aneurin Bevan University Health Board, a Falls Response Service
(FRS) has been operating since October 2016 and consists of a paramedic and
physiotherapist operating daily. This has been supported by the Welsh Government
Integrated Care Fund. The FRS has had involvement with 1961 falls incidents
received via the 999 system from October 2016 up to 31st December 2018. 1475
people (75%) have remained at home following assessment and/or treatment by the
team, with the appropriate care being provided by community-based services. Only
486 individuals (25%) required further treatment and/or treatment at hospital, and only
17% of individuals attended required treatment within the Emergency Department

The Trust is now engaging with UK Ambulance Services Project A, a national
improvement collaboration to share the Falls Framework and Falls Response model
and learn from peer organisations on how we can continue to improve our response
to people who have fallen.

In the interests of clarity, the Trust was not informed that Mrs Greenslade had fallen
and the coding given to her call by MPDS did not identify her as a lady who had fallen
and subsequently, therefore, the call was not considered for either a level 1 or level 2
response under the Fails Framework. One of the issues that the Trust is now exploring
is the value that Falls Assistants can add to our responses when patients are known
to be on their own, including engaging with careline companies to help improve the
information shared with the Trust.

The Trust uses the Resource Escalation Action Plan or REAP to provide services
during periods of increased demand or other NHS wide system pressures. The REAP
is a UK agreed document used by all 13 NHS ambulance services, with some key
actions and locally agreed operational tactics.

One of the aims of REAP is to ensure that we have a resource available for a cardiac
arrest or other high priority RED calls. In order to ensure this, the Trust reserves rapid
response units for RED calls in REAP level 3 and 4. Whilst this means that some lower
Priority calls may wait longer for a response, it does ensure that we are always able to
respond immediately to RED calls. | would like to assure you that we have reviewed

our REAP to prepare for winter 2018/19 and we now have a more dynamic approach
to managing rapid response vehicles within each health board area.

| would like, whilst writing, to respond to some of the specific matters of concern that
you highlighted in your correspondence of 21 December 2018.

1. The initial call was categorised as Green 3 without any contact being
made with Mrs Greenslade or her family and without clinical assessment.
This is consistent with processes used across Wales and the United Kingdom,
in that all 999 calls are initially assessed based on the information provided to
the call handler by the caller. Increasingly, and in cases where an ambulance
response may not be appropriate, a clinician based in one of our CCC will make
direct contact with the patient, where possible, to clinically assess the patient's
condition and provide advice over the phone (where this is appropriate).

2. After failing to make contact, no consideration was given to either

upgrading the call category or to contacting Police to ask them to carry
out a welfare check.
Whilst we have set out in this correspondence that we are reviewing our policies
and procedures around establishing contact with a patient or caller at scene,
we are of the view that it would not be appropriate to request police attendance
to undertake welfare checks for 999 calls to the ambulance service, as police
officers are not suitably trained to make a clinical assessment. However, we
are working collaboratively with our Police Force colleagues to develop a
Memorandum of Understanding regarding this issue.

3. Demand for ambulances was high compounded by excessive delays at
hospitals.
Unfortunately, this was the case and often has a material impact on our ability
to respond in a timely and reasonable way to calls that are not immediately life
threatening. As set out in the accompanying action plan, we are shortly to
commence an all Wales demand and capacity review to establish exactly what
operational capacity is required to ensure we respond in the majority of cases
within set waiting time and quality standards. This work will also assess current
demand for services and what we can expect to see in the next five years.

4. A rapid response vehicle had been based only eight minutes away from
Mrs Greensiade’s home since at least 0630 hrs and had not responded to
any Calls as it was ring-fenced for red and amber 1 calls.

Rapid Response Vehicles are assigned to ensure that we can respond quickly
as we Can to immediately life threatening situations and life threatened patients.

5. The delay in medical intervention must have played a significant role in
Mrs Greenslade’s death.
| do accept that the delay in responding to Mrs Greenslade was excessive and
fell well short of that which we set out to provide.

As the Trust has not received @ concern or claim in relation to any impact the
delay in medical intervention may have had in Mrs Greenslade’s death, we are
unable to comment on this element of your Report as an investigation into this
Specific matter has not been undertaken. That being said, the Trust will now
undertake a concerns investigation to address whether the delay did have any
impact. The investigation will be undertaken under the National Health Service
(Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

Unfortunately, the Trust does not hold the details of Mrs Greenslade’s next of
kin or representative and would welcome an opportunity to meet with the family,
to ensure that we can investigate fully.

| would like to reassure you that the Welsh Ambulance Services NHS Trust and
Aneurin Bevan University Health Board continue to work in collaboration to drive
forward the improvements. We continue to strengthen out of hospital alternative
pathways to improve efficiency and effectiveness of care for our patients and make
best use of our resources.

We hope that we have been able to assure you that we remain focused to improve our
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.

| 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 improvement
of our service provision. | would also like to extend this invite to meet with the family
of the late Mrs Greenslade and to offer our sincere condolences at this very sad time.

Yours sincerely

~

Jason Killens
Chief Executive
Welsh Ambulance Services NHS Trust

Enc: Action plan
Training plan