Andres Roberts

Dirprwy Brif Swyddog Meddygol  
Deputy Chief Medical Officer 

Dirprwy Gyfarwyddwr Gofal Iechyd Poblogaeth 
Deputy Director Population Healthcare Division 

Colin Phillips B.Sc. (Econ.) 
Acting Senior Coroner 
Swansea Neath and Port Talbot 

26th November 2020 

Dear Mr Phillips, 

Regulation 28 Report to Prevent Future Deaths – Andres Roberts 

Thank you for your letter enclosing the Regulation 28 report following your investigation into the 
death of Andres Roberts at Morriston Hospital in Swansea in August 2019. I am responding on 
behalf of Vaughan Gething, Minister for Health and Social Services. 

Please accept my apologies for the delay in responding. 

The Welsh Government and the Welsh Ambulance Services Trust (WAST) recognise the 
importance of providing a safe and timely ambulance response to suspected stroke patients, as 
a key part of their patient journey.  The Trust aims to respond to patients with new onset stroke 
as quickly as possible by dispatching a suitable emergency ambulance vehicle under blue light 
driving conditions, which is capable of transporting the patient immediately to a specialist stroke 
team to begin the treatment they require. The Trust has also put in place strong clinical 
guidance that must be followed for all suspected stroke patients, which ensures that actual and 
potential stroke patients are transferred to the appropriate settings within the clinically agreed 
guidelines. 

As part of the introduction of the clinical response model in Wales in October 2015, time-based 
targets were removed for all but the highest priority immediately life-threatening or ‘Red’ calls.  
This decision was made on the basis of clinical evidence that a higher proportion of patients in 
most need of an immediate intervention would receive a faster response to optimise their 
outcomes. 

An independent evaluation of the model1, published in January 2017, found clear and universal 
acknowledgement, both from within the ambulance service and external partners, that moving 
to a model based on clinical prioritisation was the right thing to do and has helped to deliver a 
service that is more focussed on the quality of care patients receive as well as improving 
efficiency in the use of ambulance resources.  There is also evidence that the previous practice 
of applying a time-based target for all emergency ambulance calls, irrespective of clinical 

1 https://easc.nhs.wales/publications/pacec/pacec-documents/pacec-wast-clinical-model-evaluation/  

Ffon/Tel:  03000257028 
Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ 

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

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                       
 priority, was driving perverse behaviours and resulting in poor and inefficient clinical 
interventions for patients. 

The Amber Review2, published in October 2018, questioned the value of a response time as a 
measure of the impact and quality of ambulance service care to non-immediately life 
threatening calls.  While this does not mean that time is not important, it highlights that the initial 
ambulance response is part of a patient journey and that ensuring patients receive the most 
appropriate response and timely access to the right specialist treatment is often more important 
to ensure a good patient outcome, particularly for conditions such as acute myocardial 
infraction and stroke. 

The Review made nine recommendations and identified a number of areas where further work 
was required to gain an improved understanding of the challenges and opportunities to improve 
responses  to  calls  in  the  ‘Amber’  category.    While  it did  not make any  specific conclusions  or 
recommendations relating to ambulance response to stroke, the Emergency Ambulance Services 
Committee  (EASC)  is  committed  to  developing  the  Ambulance  Quality  Indicators  to  include  a 
broader range of meaningful measures for strokes and other time dependent conditions, while 
protecting the integrity of the clinical response model.   

Discussions  are  ongoing  between  EASC  and  WAST,  in  consultation  with  Community  Health 
Councils, the Stroke Association and its patients groups, and NHS Wales partners, to consider a 
broader range of measures that give greater context to ambulance response times to people who 
have a stroke, for publication in the New Year.  We hope that delivery of a new measure can be 
a  major  step  forward  in  understanding  the  current  care  being  delivered  for  stroke  patients  in 
Wales and to allow us to focus on improving the right area of the pathway. 

We also continue to work with WAST and Health Boards to implement the recommendations of 
the NHS Wales Delivery Unit All-Wales Thrombolysis Review, published last year. The review 
identified a number of national cross-cutting themes across Wales that would benefit from an 
all-Wales approach and made a number of personalised recommendations for WAST and 
Health Boards to address the variation in the number of people who receive thrombolysis in 
Wales. Whilst Covid-19 and the retirement of the national clinical lead for stroke has slightly 
delayed progress, the new clinical lead for stroke in Wales, Dr 
ensuring that all outstanding review recommendations are implemented as soon as possible. 

 is committed to 

I note your concerns regarding resources available to enable WAST to respond to calls in a 
timely manner.  The Trust is currently implementing the recommendations of an independent 
capacity and demand review, which will see 136 FTE staff recruited in 2020/21, significantly 
increasing the number of frontline staff available across the service to respond to incidents. This 
should support an improvement in responsiveness, although the wider health and care system 
also has a role to play in enabling improved patient flow through the hospital system and out 
into the community. This should reduce ambulance patient handover delays and unlock more 
capacity to respond quickly.  A range of actions are also underway to better manage patient 
demand in the community to help prevent avoidable transport of patients to hospital. 

We continue to work with NHS Wales and social care partners to support improvement across 
health and social care services, and through the COVID-19 NHS Wales Operating Frameworks 
for quarter 2 and quarter 3 / quarter 4, we have outlined six goals for urgent and emergency 
care services over 2020/21 and beyond: 

2 https://easc.nhs.wales/publications/amber-review/amber-review-documents/amber-review-english/  

 
 
 
 
 
 
 
                       
 1.  Co-ordination, planning and support for high risk groups - Planning and support to 
help high risk or vulnerable people and their carers to remain independent at home, 
preventing the need for urgent care 

2.  Signposting, information and assistance for all - Information, advice or assistance to 
signpost people who want - or need - urgent support or treatment to the right place, first 
time. 

3.  Preventing admission of high risk groups - Community alternatives to attendance at 
an Emergency Department and/or admission to acute hospital for people who need 
urgent care but would benefit from staying at, or as close as possible, to home. 

4.  Rapid response in crisis - The fastest and best response at times of crisis for people 
who are in imminent danger of loss of life; are seriously ill or injured; or in mental health 
crisis. 

5.  Great hospital care - Optimal hospital based care for people who need short term, or 

ongoing, assessment/treatment for as long as it adds benefit. 

6.  Home first when ready - A home from hospital when ready approach, with proactive 

support to reduce chance of readmission 

Through delivery of this approach, key local and national interventions, and development of 
underpinning operational plans, we will work with national, regional and local partners to 
change the ways that patients access urgent and emergency care services to ensure they are 
able to receive advice, assessment and treatment from the right place / setting / clinician, first 
time. 

We have also made £30m additional funding available to enable transformation of urgent and 
emergency care services and increase resilience over the remainder of 2020/21, including four 
priorities to optimise patient flow, experience, outcome and value when people access urgent 
and emergency care services:  

  111/contact first models to enable patients with urgent care needs to be signposted to the 

right place, first time.  

  24/7 urgent primary care centre models of care to enable people to access care in their 

local community, preventing unnecessary attendances at ED  

  Ambulatory or same day emergency care (AEC/SDEC) to enable patients to safely 

bypass the ED and prevent unnecessary admission  

  Four discharge to recover then assess pathways (D2RA), to prevent unnecessary 

admission and enable a home first approach.  

You  may  also  wish  to  be  aware  that  a  Ministerial  Ambulance  Availability  Taskforce  has  been 
established  to  focus  on  ambulance  responsiveness  and  the  need  for  wider  whole-system 
improvements to reflect and respond to the changing environment in which ambulance services 
are delivered. This includes the changing picture of demand and performance for immediately 
life-threatening (Red) calls, ambulance patient handover delays and the wider health and social 
care  landscape.  The  taskforce  will  have  a  key  role  to  play  in  delivering  a  more  effective 
ambulance response and while it was temporarily stood down to enable a focus on the response 
to  Covid-19,  but  its  work programme  has been  resumed and  will be expedited,  with  a  view  to 
submitting its interim report to the Minister by the end of December 2020. 

I hope this is helpful. 

Yours sincerely,

Cadeirydd 
Chair: 

Prif Weithredwr 
Chief Executive: 

Swyddfa'r Prif Weithredwr a’r Cadeirydd  

Chair and Chief Executive’s Office 

Our Ref: 

13 November 2020 

Private & Confidential 
Mr Colin Phillips BSc (Econ) 
Acting Senior Coroner for Swansea 
Coroner’s Office 
Civic Centre 
Oystermouth Road 
Swansea 
SA1 3SN 

Dear Mr Phillips 

Inquest into the death of Andres Roberts 

I write in response to the Regulation 28 Report that you issued on 23 September 2020, following 
the sad death of Mr Andres Roberts. In the report you raised your concerns in relation to three 
matters, namely: 

Matters of concern noted in the Regulation 28 report: 

1.  The appropriateness of the grading of stroke patients falling in the amber category; 

2.  Whether a specific time target should be set;  

3.  Whether  additional  resources  should  be  made  available  to  the  Trust  to  meet  these 

targets. 

  Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg 

neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi 

The Trust welcomes correspondence in Welsh or English, and 
that corresponding in Welsh will not lead to a delay 

www.ambulance.wales.nhs.uk 

Pencadlys Rhanbarthol 
Ambiwlans a Chanolfan 
Cyfathrebu Clinigol 

Regional Ambulance 
Headquarters and 
Clinical Contact Centre 

Tŷ Vantage Point 
Vantage Point House 
Tŷ Coch Way 
Cwmbran NP44 7HF 

Ffôn/Tel  
01633 626262 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Following receipt of the Regulation 28, and consideration of the facts within, I would sincerely 
appreciate the opportunity to discuss these with you, as the Trust does not propose, at this time, 
to take any action in relation to the three matters you have raised. The reasons for which I will 
explain below.  

Each ambulance service has a response model that supports the categorisation given to each 
call (irrespective of which prioritisation system is used). That response model and the decisions 
made will reflect the demographics of the population and the geography being served by that 
individual ambulance service. In 2015 the Welsh Ambulance Services NHS Trust introduced its 
current  Clinical  Response  Model  (the  Model),  which  removed  timed  targets  for  all  but  those 
patients  with  immediately  life-threatening  illnesses  or  injuries.  The  Model  underwent  a  trial 
period before being approved by the Welsh Government and fully implemented by the Trust. 

The Trust’s Model is in line with England. In England ambulance services operate a national 
system of response prioritisation following the introduction of the Ambulance Response Program 
(ARP).    More  information  regarding  the  Ambulance  Response  Program,  which  reflects  the 
at 
here 
Clinical 
https://www.england.nhs.uk/urgent-emergency-care/arp/.  

Response  Model 

in  Wales, 

found 

used 

can 

be 

It is therefore correct to say that England operates a universal, i.e. national system of response 
prioritisation  and  that,  in  line  with  the  system  operated  here  in  Wales,  only  when  stroke 
symptoms identify that a patient is unconscious and not breathing does it attract a red response 
category. 

Stroke calls in the English response model are prioritised as either Category 2 (second highest 
priority, of five) or Category 3 (third highest priority).  These categories are aligned to Amber-1 
and Amber-2 priorities in Wales (which also represent the second and third highest priorities, 
respectively). The primary determinant of whether a call for a patient with suspected stroke is in 
the  Amber-1  or  amber-2  priority,  is  the  time  onset  of  symptoms,  as  more  recent  onset  of 
symptoms  are  a  higher  priority,  if  the  patient  is  still  within  the  window  of  opportunity  for 
thrombolysis. 

The appropriateness of the priority given to each category of call is reviewed and changes are 
considered by the Trust’s Clinical Priority Assessment Software (CPAS) Group. In all cases the 
group will consider the impact any change would have on the volume of Red calls received, the 
effect of increasing the Red calls and the impact on other codes. The CPAS group also sets an 
“ideal” response for each type of call, in an attempt to maximise efficient use of resources by 
avoiding “double dispatch” on calls. If a patient is suffering a stroke, the dispatch of a paramedic 
in a car (rapid response vehicle) does not aid the patient directly, as the key treatment (if stroke 
is suspected) is conveyance to hospital for brain scans and consideration for thrombolysis. Thus 
the  paramedic  in  an  RRV  would  only  be  able  to  confirm  the  likely  diagnosis,  and  request  a 
conveying ambulance to attend. The clinically important time is therefore not the time taken to 
respond to the 999 call, but the time taken from onset of symptoms until arrival at hospital. 

I would respectfully like to advise you that not all patients displaying possible symptoms of a 
stroke are prioritised as an Amber call. Some patients will be prioritised as Red, some Amber 
and  others  Green,  dependent  on  their  symptoms.  The  Trust’s  model  aims  to  attend  patients 
dependent on the severity of their symptoms, with the correct vehicle, as soon as possible. 

It would however, be right to offer balance in this respect, in that whilst over 50% of patients who 
attracted a response category of Amber 1 during 2019/20 received a response within 27 minutes 
there are clearly a number of patients who do regrettably wait longer that we would like. 

2 

 
 
 
 
 
 
 
 
 
 In closing, I am of the view that the principle issue for us here is not one of categorisation as it 
is right to have a system of priority that assigns more rapidly to clinical severity.  

In relation to whether additional resources should be made available to the Trust to meet these 
targets, the Trust has undertaken a Demand and Capacity review, which has identified the need 
for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority 
of these additional staff will be introduced over the next 4 years to increase the relief capacity 
within the current rosters, allowing for increased ambulance provision to meet demand.  

At  the  time  of  this  specific  incident  there  were  significant  delays  in  transferring  the  care  of 
patients  from  ambulance  to  hospital  staff.  Specifically,  there  were  9  emergency  ambulances 
awaiting to handover their care to hospital staff, with the longest wait in excess of 8hours.  

When  vehicles  are  delayed  at  hospital  this  effects  our  ability  to  respond  to  patient’s  in  the 
community  and  causes  significant  pressures  upon  our  services.  Accordingly  the  Trust  has 
developed  a  Demand  Management  Plan  to  manage  actions  across  our  services  at  times  of 
escalated pressure. 

Another action that is being taken forward is to offer support at challenging times include the 
Operational Delivery Unit (ODU). The ODU is a pilot model designed to provide 24/7 leadership 
in support of the Welsh Unscheduled Care system, and as a central hub to co-ordinate flow and 
mitigate potential  risks  to  patient  care.  To date  it  delivers  16  hours  a day  operating  between 
08:00-midnight, which was reduced in August 2020 to 12 hours a day. 

The ODU has a dual role in providing an independent leadership role to facilitate collaboration 
with  Health  Board  partners  in  parallel  to  being  aligned  to  the  Welsh  Ambulance  Operations 
directorate supporting Emergency Medical Services operations. 

It has been designed to monitor the daily situation and consider actions that may impact upon 
the delivery of care, utilising principles that seek to pre-empt, mitigate, and react to any issues 
that may arise.  The National Delivery Manager is the senior on duty decision maker out of hours 
in support of on call teams and helps reduce the need to use on call staff that have been on duty 
in the day.    

It has developed a close working relationship with site teams that are responsible for the flow of 
patients through the hospital which enables early dialogue when delays occur.   The ODU will 
provide the sites with details of calls polling (waiting) in the community as an early predictive 
indicator  of  demand 
to  need  an  Emergency  Department 
admission.  When delays start to occur the ODU will contact the site to establish a time line for 
transferring patients and will discuss any divert options if appropriate.   

is  potentially  going 

that 

If there is a high volume of calls in any particular area the ODU will liaise with the Clinical Support 
Desk shift lead to discuss targeting proactive clinical support to help discuss alternative options 
for patients other than Emergency Departments.    

3 

 
 
 
 
 
 
 
 
 
 
 
 
 It  works  closely  with  bed  management  teams  to  encourage  early  discharge  transport 
arrangements  so  that  delays  for  patients  to  be  discharged  home  are  minimised  and  Non-
Emergency Patient Transport Service ambulances are appropriately utilised.  

I can provide you with assurance that the Trust continues to work with all Health Boards across 
Wales  to  address  the problems  associated with  our  ambulances  (be  that  Emergency,  Urgent 
Care  or  Rapid  Response  Vehicles)  being  delayed  at  hospital.  I  personally  wrote  to  the  Chief 
Executive  Officers  of  the  Health  Boards  across  Wales  in  August  of  this  year  to  share  my 
concerns regarding the pressures on our services when our resources are delayed at hospitals. 

The  Trust  has  various  ongoing  actions  to  help  reduce  the  pressure  on  busy  hospital 
departments,  which  will  improve  patient flow  within  the  wider  NHS  system  and  maximise  the 
availability of our emergency ambulances for our most critical patients. 

•  We have expanded our clinicians on the clinical desk in our 999 control room to support 
timely clinical assessment and to ensure we are sending the appropriate resource to the 
individual patient. 

•  We are working in collaboration with the Health Board to develop out of hospital pathways 

to safely reduce the need to convey patients to hospital. 

•  We also support the discharge and transfer of patients out of hours in order to release 
beds in hospitals, which in turn supports the improvement of patient flow in the emergency 
departments. 

•  Where safe to do so, the Trust aims to support people in the community and to reduce 

the number of unnecessary admissions to Emergency Departments. 

•  We continue to recruit and train Advanced Paramedic Practitioners who have a higher 

skill level and are trained to treat patients at their own homes, where possible. 

I hope that I have been able to assure you that we remain focused to provide the best possible 
service for the people of Wales. 

I would like to extend the offer to meet with you to discuss our response in more detail and to 
provide you with any further assurances you require regarding our commitment to continuous 
improvement. 

Yours sincerely 

Chief Executive   

Encl: Action Plan 

4