Barbara Young

Swyddfa'r Prif Weithredwr a’r Cadeirydd 

Chair and Chief Executive’s Office 

24 March 2022 

PRIVATE & CONFIDENTIAL 
Ms Caroline Saunders 
Senior Coroner for Gwent 
(Sent by email: gwent.coroner@newport.gov.uk) 

Dear Ms Saunders 

Re: Barbara Young 

I  am  writing  in  response  to  the  Regulation  28  Report  that  you  issued  to  this  Trust,  dated  28 
January 2022, following the sad death of the late Mrs Barbara Young. 

In  the  Regulation  28  Report  you  raised  your  concerns  in  relation  to  two  matters,  which  I  will 
respond to below:- 

1.

Confirm  the  action  that  will  be  taken  to  improve  the  response  times  of
emergency ambulances.

To  put  this  response  in  some  context,  you  may  be  aware  that  during  the  first  wave  of  the 
pandemic,  we  saw  a  reduction  in our normal  demand,  in  addition  there were fewer delays  in 
handing over patients at hospital. 

However, subsequently during 2021 and 2022, activity returned not just too forecasted levels, 
but  above  predicted  levels.  This  is  further  exacerbated  by  an  increase  in  the  acuity  of  our 
patients. As a result of this, the Welsh Ambulance Services NHS Trust (The Trust) continues to 
experience excessive delays in trying to respond to patients in our communities and handing 
patients  over  at  hospitals  for  assessment,  care  and  treatment.  There  have  also  been  other 
contributory factors why there have been delays in providing a timely response which include, 
sickness absence, infection prevention and control measures and also delayed transfers of care 
out  of  hospital  because  of  a  lack  of  social  care  packages.  This  will  mean  that  patients  are 

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 

 
 
 
 occupying acute hospital beds as it would be unsafe to discharge home without adequate social 
care in place.  

I can confirm, as with all NHS Organisations, staffing has been significantly affected during the 
pandemic, with as many as 15% of staff away from work at any one time as a result of sickness 
absence, a significant proportion linked to Covid-19, whether that be the result of contracting the 
infection themselves, self-isolation or indeed, during the initial waves, shielding. This inevitably 
had  a  bearing,  and  continues  to  do  so,  on  our  ability  to  optimise  the  number  of  ambulances 
available to respond. 

In addition, for Red calls, crews are required to wear additional personal protective equipment 
(PPE) which can add crucial minutes to put on, when crews arrive at scene. We recognise this 
is difficult, but we have a responsibility to safeguard our own crews where there is a risk to them 
and we follow national guidance on this matter. 

During February 2022, the Welsh Government (WG) called a Risk Summit with all NHS providers 
and Local Authorities to review patient risks in the community and to identify what improvements 
could and should be made to improve system pressures. This meeting resulted in a mandate 
from WG for all Health Boards and Local Authority partners to work collaboratively to introduce 
a system reset during March 2022. In addition, Chief Executives of Health Boards have been 
asked to urgently provide their plans for how they will reduce hospital handover delays over the 
coming weeks. 

I am able to provide you with absolute assurance that the negative and sometimes catastrophic 
impact  the  systems  pressures  are  having  on  patients  in  our  communities  is  constantly  being 
reviewed and escalated at the highest level. I can also assure you, that the Trust has already 
taken  many  actions  to  try  and  mitigate  the  effects  of  ambulances  being  delayed  at  hospital, 
which  then  effects  our  ability  to  respond  to  people  in  the  community.  As  I  am  sure  you  will 
appreciate, none of these matters sit in isolation but are interlinked. I wish to assure you that the 
Trust has made several changes and taken actions, over and above those I have listed here. 
However, I have selected the issues and actions that I hope best demonstrates that the Trust 
has considered every possible way in which we can react to and mitigate the impact of these 
pressures, which are fundamentally outside of our control. These include: 

Consult and Close 

There has been significant investment into the Clinical Contact Centre (CCC), where by the end 
of  the  month  we  have  doubled  our  clinical  workforce  in  this  area  (Nurses/Paramedics/Mental 
Health Practitioners), which is already showing some improvement in unnecessary dispatch and 
conveyance into hospital, where appropriate. The additional clinicians in the CCC are offering 
patients appropriate alternatives such as for example, signposting to pharmacist, having an up 
to date Directory of Service to local pathways, and, or giving self-care advice and support. This 
will release vital resources to respond to patients who need a face to face assessment in the 
community. We anticipate with this investment that we will be able to consult with our patients 
and close up to 15% of the calls we receive.  

Handover Delays 

Unfortunately the Trust continues to see a substantial number of hours lost to hospital handover 
delays,  across  NHS  Wales,  with  more  than  25,000  hours  lost  (25%  of  our  on  duty  fleet)  in 
February 2022. This has a significant impact on our ability to provide timely care and treatment 
to those in need an emergency community response. The Trust, continues to work closely with 
our Health Board colleagues across Wales to minimise delays by providing on-site support and, 

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 with  assistance  from  nursing  and  medical  staff,  prioritising  those  patients  with  the  greatest 
clinical  need. As  an  example, a  number  of Patient  Flow  Coordinators  have  been  recruited  to 
support  the  wider  system  flow  pressures  at  the  Grange  Hospital,  Cwmbran.  In  addition,  we 
secured support from Private Ambulance Service clinicians over the winter months. The purpose 
of  the  approach  is  to  facilitate  safe  timely  transfers  for  a  cohort  of  patients  from  the  Trust 
ambulances when there is no capacity within the Emergency Department (ED) or elsewhere in 
the hospital to facilitate timely off-load. That said, delayed transfer of care remains a significant 
barrier our ability to respond to calls in the community in a timely fashion with 25% of our on duty 
fleet capacity lost in this way in February.  

Discharge and Transfer 

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. 

Reducing Conveyance to ED Departments 

Where safe to do so, and where Health Boards have suitable alternative clinical pathways, 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 in their own homes, 
where possible. 

Additional Capacity from Military   

You may be aware that we have had support from the military on three separate occasions, the 
latest deployment being scheduled to finish at the end of March 2022. We have asked for military 
support  to  help  us  put  out  as  many  ambulances  as  possible,  as  well  as  securing  additional 
support from St John Cymru Wales, other providers and utilising our own staff differently. 

Clinical Safety Plan (CSP) 

To support the Trust to be able to manage and respond to those patients in greatest need, the 
Trust has reviewed and enhance the process around the Clinical Safety Plan (CSP). This allows 
the Trust to manage the demands on the service differently during times of extreme pressure. 
The introduction of the CSP ensures that patients are advised of the current timeline of delay, 
and would be encouraged to contact family members, neighbours or friends to help assist with 
transport to hospital, should this be an option. This provides a framework for Trust Emergency 
Operations teams to respond dynamically to situations through a set of tactical options that are 
flexible,  immediate  and  specific  to  each  Health  Board  area.  This  ensures  that  patients  with 
immediately  life-threatening  conditions  such  as  cardiac  arrest  and  catastrophic  hemorrhage, 
continue  to  receive  services  as  quickly  as  possible.  The  CSP  has  been  approved  by  Trust 
executives and the senior management team, and it is accepted that in times of extraordinary 
pressure, the Trust will be unable to provide the level of response that would be desired. It is 
therefore appropriate to inform some callers of likely delays and advise them to seek alternative 
arrangements  to  ensure  that  the  patient  is  taken  to  a  facility  that  can  provide  appropriate, 
definitive care.  

Demand & Capacity 

To  ensure  that  the  Trust  has  the  correct  number  of  resources  available  to  respond  to  the 
expected demand and maximise the number of resources available to respond to patients, the 
Trust undertook a Demand and Capacity Review. This review identified a range of efficiencies 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 for the Trust to achieve. This includes a full roster review and some focused improvement work 
on the management of sickness and absence.  

Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. 
The  staff  have  been  recruited  and  trained  as  part  of  our  established  Emergency  Medical 
Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 
22/23 to ensure staff are on duty at the time and in the place that best match patient demand. 
This will release an internal efficiency equivalent to 72 FTE.  

All of the actions above assist by reducing the pressure on busy hospital departments, improve 
patient  flow  within  the  wider  NHS  system  and  maximise  the  availability  of  our  emergency 
resources for our most critical patients. 

2. 

Confirm whether there are any plans to review the categorisation of elderly patients 
who  suffer  falls  and  are  more  likely  to  be  affected  by  the  risks  associated  with 
lengthy periods of immobility. 

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 appropriateness of the priority given to each category of call is reviewed and changes are 
considered  by  the  Trust’s  Clinical  Priority  Software  Advisory  Group  (CPAS).  In  all  cases  the 
group will consider the impact any change would have on the volume of each priority of calls 
received, for example the effect of increasing the number of Red calls would have an impact on 
all 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.  

The Medical Prioritisation Dispatch System (MPDS) does not provide a determinant code based 
on age within Protocol 17 (falls) which would prevent a specific prioritisation change for elderly 
patients.  The principal role of the Clinical Support Desk (CSD) Clinician is to provide additional 
clinical triage, advice and support to patients to ensure that they can access the most clinically 
appropriate care for their urgent and emergency healthcare needs, commonly known as Hear 
and Treat (H&T). In addition to this principal role, the CSD also undertake a range of other clinical 
functions  in  pursuance  of  maximising  patient  safety  for  those  awaiting  an  emergency 
ambulance.   This  includes  reviewing  long  waiting  patients  to  maintain  patient  safety.   CSD 
clinicians have the ability to change the responding priority of an incident based on a secondary 
clinical  assessment,  this  includes  increasing  the  priority  where  the  patient’s  clinical  acuity 
indicates  this  is  appropriate.   Dispatch  guidelines  regarding  falls  and  frailty  responders  are 
continually reviewed and updated to ensure maximum utilisation of this valuable resource, part 
of the CSD role is to provide support to falls assistants following an initial assessment to ensure 
the correct outcome is reached.  

The categorisation of elderly patients who suffer falls and are more likely to be affected by the 
risks associated with lengthy periods of immobility, will be referred to the Trust’s Clinical 
Priority Software Advisory Group. 

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 Additionally, in 2018, Working in partnership with St John Cymru Wales, the Trust introduced 
the role of the Falls Assistants (FA). The FA predominately provide a response to patients who 
have no injuries or where there is a concern for welfare. However, they are able to respond to 
patients with other medical/frailty presentations, or if there is an injury. This decision will often 
be  supported  by  a  clinical  triage  and  assessment  by  a  clinician,  over  the  phone,  prior  to 
allocation.  The aim of this new level of response was to ensure those patients often presenting 
with  lower  clinical  acuity,  were  provided  with  a  timely  response  to  reduce  the  risk  of  further 
harm.   

Within  2021,  the  Trust  successfully  awarded  a  contract  to  provide  a  National  Falls  Assistant 
Service with one Falls Assistant (for 12 hours per day) in each Health Board area, to St John 
Cymru Wales. From December 2021 through to January 2022, the Quality Improvement Team 
are currently working with various stakeholders both internally and externally to further enhance 
the  Falls  Assistant  provision.  This  includes  the  Operations  and  Clinical/Medical  Directorate, 
along with Health Board Partners. We have introduced a further two vehicles by night (funded 
by the Trust) which is currently funded up to and including 31st March 2022.  

Outside of our contract with St John, one vehicle has been funded by the Cardiff and the Vale 
Health Board (operational from 19.30-07.30), which is currently funded up to and including 31st 
March  2022.  Additionally,  Aneurin  Bevan  University  Health  Board  continues  to  fund  a  Falls 
Response Service (Paramedic and Therapist) vehicle which operates daily (08.00-20.00hrs) and 
Betsi  Cadwaladr  University  Health  Board  are  currently  funding  a  trial  for  a  Falls  Response 
Service model which operates 4 days per week. Swansea Bay University Health Board have 
agreed to fund a Falls Response Service provision for 1 day per week over the winter period, 
providing ad-hoc cover. In addition to the specialist falls response, the Trust are working with 
volunteers (community first responders) and Fire and Rescue Services to provide a designated 
response to patients who have fallen to ensure periods of immobility are reduced. Enhanced 
Clinical  Desk  capacity  has  been  introduced  with  the  Clinical  Contact  Centre,  which  ensures 
patients  receive  targeted  advice  when  waiting  for  a  response  including  advice  in  relation  to 
pressure ulcers and reducing the period of immobility. This is provided as part of the telephone 
triage and assessment.  

The Trust continues to work with partners to further expand the model, to ensure patients are 
able to receive a timely response.  In December the Trust undertook a review of the Medical 
Priority  Dispatch  System  (MPDS)  codes  for  Falls  to  determine  if  there  were  opportunities  to 
improve the timeliness of response. Following a review, four codes were identified as suitable 
for Falls Assistants (non-registered, in some areas St John Service) to attend without the need 
for  Clinical  Triage, 
send  an  Emergency 
Ambulance.  Furthermore, improvements are actively being considered to improve utilisation of 
resources  and  support  patients  who  are  waiting  for  a  response.  A  Quality  Improvement 
Workshop  has  been  prioritised  for  April,  with  representatives  from  across  the  organisation  to 
identify  tests  of  change  and  prioritise  improvements.  This  includes  a  review  of  the  advice 
provided via 999 and a review of the response availability and capacity. The Falls Improvement 
and  Implementation  Group  (FIIG)  will  conduct  a  review  of  the  guidance  provided  to  patients 
following a fall, consider the risks associated immobility and will suggest possible improvements. 

requirement 

reducing 

thus 

the 

to 

To conclude, and to provide you with absolute assurance, the Trust is aware of the risks and the 
impact that delays in care and treatment can have on patient outcomes. This is not the level of 
service that we want to provide for the people in Wales. I hope that this response as provided 
you with a level of assurance that we, as an organisation, are doing everything in our control to 
reduce the level of risk, harm and the impact that the system pressures is having on patients in 
our communities. 

5 

 
 
 
 
 
 
 
 
 Whilst writing I would like to extend my sincere condolences to Mrs Young’s family on their sad 
loss.  I would also 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 may require regarding our commitment to 
continuance improvement to support the prevention of future deaths. 

Yours sincerely 

Chief Executive 

Enc:  Action Plan 

6