Gwynne Samuel

Swyddfa'r Prif Weithredwr a’r Cadeirydd  

Chair and Chief Executive’s Office 

8 August 2022 

Private & Confidential 
Ms C Saunders 
Senior Coroner for Gwent 

Dear Ms Saunders 

Re: Mr Gwynne Samuel 

I write in response to the Prevention of Future Deaths Report issued to this Trust on 17 June 
2022, following the inquest in relation to Gwynne Samuel. 

You asked that the Trust to consider two specific issues: 

1)  Confirmation whether the effect of long lies in elderly patients is understood and 

taken into account during the categorisation process. 

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 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

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 this 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 at least one Falls Assistant (for 12 hours per day) in each Health Board area, to St 
John Cymru Wales. A total of eight Falls Assistants operate by day. 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 WAST) which is currently funded up to and including the 31st March 2023. There are 
a total of 10 Falls Assistants available per 24 hour period across Wales. 

Aneurin Bevan University Health Board and Gwent Regional Partnership Board, continues to 
fund a Falls Response Service (Paramedic and Therapist) vehicle which operates daily (08.00-
20.00hrs). Additionally Betsi Cadwaladr University Health Board and the North Wales Regional 
Partnership Board, are currently funding two Falls Response Services teams,   which operate 
on weekdays within the East and Central areas. 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.  

2 

 
 
 
 
 
 
 
 
 thus 

reducing 

The Trust continues to work with partners to further expand the model, to ensure patients are 
able  to  receive  a  timely  response.   In  December  2021  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  August  2022,  with  representatives  from  across  the 
organisation to identify tests of change and prioritise improvements. This has been delayed due 
to  high  levels  of  escalation  within  the  organisation.  However,  it  will  be  essential  to  seek 
opportunities  to  increase  the  levels  of  utlisation  of  falls  resources,  ensuring  we  are  able  to 
maximise  response  capacity  across  Wales.  The  newly  formed  Older  Persons  Improvement 
Group (OPIG), will conduct a review of the guidance provided to patients following a fall, consider 
the  risks  associated  immobility  and  will suggest  possible  improvements,  as part of the newly 
formed group, due to meet in August 2022.  

requirement 

the 

to 

Currently long lie falls calls are reviewed by CSD and upgraded as and when appropriate. 

The recent update to ProQA (the system for monitoring data within MPDS) released on 10th May 
2022  has  split  the  MPDS  code  suffix  relating  to  falls  on  the  ground  or  floor  and  added  time 
targets as below: 

  On the ground floor < less than an hour or unknown 
  On the ground/floor 1-2 hours 
  On the ground/floor > 2hours 

There have been discussions at the National Ambulance Service Medical Executive Directors 
Group (NASMED) as to whether there should be further MPDS code suffixes for falls longer than 
two  hours.  NASMED  has  also  highlighted  the  issue  relating  to  calls  just  inside  a  time  target 
window and calls where there is no further contact as the call does not automatically change if 
the  call  falls  outside  the  MPDS  code  suffix  window  therefore  there  will  be  some  patients 
disadvantaged for not calling back. 

For this reason, the Trusts CPAS has agreed to prioritise the three variations the same initially 
as the original categorisation of the code – on the ground or floor and monitor data and further 
updates from NASMED. The rational for this decision is that due to current demand pressures it 
is unlikely the Trust will be in a position to send a response or do something differently in the 
time  targets  allocated  to  the  each  MPDS  code  suffix.  This  decision  is  subject  to  review  and 
change based on further updates from NASMED. The Older Persons Improvement Group, will 
review  data  from  the  new  MPDS  code  and  suffix  to  consider  recommendations  to  CPAS  in 
relation to whether there would be a benefit to different priorities being assigned to codes, due 
to less than 1 hour, 1-2 hours or over 2 hours. This will need to be balanced and proportionate 
in respect to other clinical presentations.  

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. 

3 

 
 
 
 
 
 
 
 
 
 
 2)  Confirmation of the current waiting times for Amber 1 and Amber 2 responses 

and any plans in place to improve responsiveness. 

The average response times to Amber 1 calls in the Aneurin Bevin University Health Board area 
is currently 2 hours, 29 minutes and 15 seconds. With response time to Amber 2 calls in the 
same area being 4 hours, 36 minutes and 9 seconds. 
Below are graphs which illustrate the response times to Amber 1 and Amber 2 calls in the Health 
Board area over the past 54 full years, along with this year to date. 

4 

 
 
 
 
 
 
 
 
 
 The Trust is the national all Wales provider of 999 and Emergency Medical Services (EMS); 111 
urgent remote clinical advice and Non-Emergency Patient Transport Services (NEPTS) with a 
workforce of over 4000 and operating a fleet of over 700 vehicles from more than 100 premises 
nationwide. The Trust annual revenue turnover is more than £260m. During the pandemic the 
Trust has also nationally operated mobile COVID testing units. 

The Trust welcomes the opportunity to provide this response, which outlines the circumstances 
and  nature  of  the  Service’s  current  operating  context,  the  factors  which  have  contributed  to 
current pressures and the efforts the Service is making to alleviate those pressures. 

The  issues  outlined  in  this  document  are  evidenced  in  the  supporting  data/information  pack 
(Appendix 1).  

In providing this response the Trust Board acknowledges that H.M Coroners across Wales have, 
over several years, recorded Prevention of Future Deaths reports and other recommendations 
in respect of health services in Wales, including the Welsh Ambulance Service (the Trust).  

Such recommendations are taken extremely seriously by the Board. In spite of the efforts made, 
there  is  an  acknowledgement  that  progress  in  stabilising  and  improving  ambulance  service 
response times across has not been as rapid, or as effective, as would have been wished.  

This  response  sets  out  several  key  issues  which  have  served  to  adversely  affect  the  Trust’s 
performance in recent years, including during the Covid-19 pandemic, and particularly in the first 
half of the 2022 calendar year.  

It also sets out the steps taken to improve matters so far and the likely position moving forward.  

Background  
The Trust is commissioned by the seven local health boards (LHBs) in Wales via the Emergency 
Ambulance Services Committee (EASC).  

The Committee is formed by the Chief Executives of the seven LHBs and presided over by an 
independent  Chairperson  appointed  by  the  Health  Minister.  EASC  has  appointed  a  Chief 
Ambulance  Services  Commissioner  (CASC)  to  undertake  a  lead  role  in  supporting  the  local 
health  boards  in  commissioning  emergency  ambulance  services  from  the  Trust  within  the 
context  of  the  wider  unscheduled  care  system  (and,  from  2016,  Non-Emergency  Patient 
Transport Services in Wales).  

The arrangements effectively create a commissioner/provider relationship in which the seven 
LHBs  are  collectively  responsible  for  securing  the  provision  of  an  effective  emergency 
ambulance service for Wales. The Trust, therefore, is responsible for supplying the urgent and 
emergency medical services that the LHBs require, based on a commissioning framework.  

Commissioners  set  commissioning  intentions  on  an  annual  basis  reflecting  the  service 
standards and operational performance developments they expect to see.  

The Trust finances flow largely via EASC, with further monies coming either directly from Welsh 
Government or individual health boards, where they choose to commission additionality for their 
populations.  

Since October 2015, the Trust’s clinical response model has been predicated on clinical outcome 
rather than target response time, save for its one formal target of responding in eight minutes to 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 65% (nationally) of calls which fall into the RED category, namely those which are categorised 
as immediately life threatening.  

Prior to  the  Covid-19  pandemic,  national performance  had  generally  been  at  or above  target 
since 2015, although decaying performance had started to become apparent more latterly and 
there were geographic variances in performance that had not been entirely eradicated.  

Right-sizing the Organisation  
Against  that  backdrop  of  a  gradual  erosion  of  performance,  in  2019  a  national  Demand  and 
Capacity Review  was commissioned.  

The review, which was led by world leaders in ambulance forecasting and modelling, Operational 
Research  in  Health  (ORH),  and  was  undertaken  collaboratively  on  behalf  of  the  Emergency 
Ambulance Services Committee (EASC), was itself an output of the Welsh Government’s Amber 
Review published in 2018.  

The Demand and Capacity Review was carried out through 2019 and its outcome was formally 
reported  to  EASC  in  January  2020  where  all  of  the  recommendations  from  the  review  were 
endorsed.  

One of the main findings of the Amber Review, was that many patients in the amber category of 
serious but not immediately life-threatening calls were waiting too long because of challenges 
relating to ambulance availability.  

The Review identified that the Trust had a gap between the number of full time equivalent (FTE) 
staff funded to fill its response rosters and the number of FTEs required to fill those rosters. This 
is referred to as the “relief gap”.  

The ORH concluded that bridging the gap would require an investment of 263 staff on a full time 
equivalent (FTE) basis across Wales. The Emergency Ambulance Services Committee (EASC) 
agreed to invest in the Trust, over a two year period – 2020/21 and 2021/22, and close the “relief 
gap”, while it was agreed re-rostering would help improve the alignment and mix of resources 
allied to patient demand.  

Throughout the pandemic, work has continued to recruit the additional staff and progress with 
the roster review, as key planks  in the Trust’s response to the need to stabilise and improve 
performance long term. The Trust delivered an uplift in staff numbers in 2020/21 of 136 FTEs 
and 127 FTEs in 2021/22 with the final groups of staff concluding their training and becoming 
operational in Q1 22/23.  

In the same time period, the Trust agreed to take steps to reduce abstractions due to sickness 
absence, to increase ‘hear and treat’ rates (where patients are triaged and given advice rather 
than deploying an ambulance) to 10.2% and to implement new rosters across Wales.  

The ORH modelled that, with this additional resource in place, the Trust efficiencies delivered 
and a reduction in hospital handover delays to December 2018 levels, a national red response 
rate of 67.3% within 8 minutes and an amber 1 mean response time of 34 minutes would be 
achieved at the end of 21/22.  

6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Performance Pressures  
There are several factors in combination which have led to the significant performance pressure 
under which the Trust now finds itself.  

In broad terms, these pressures can be defined as:  
a) Increased demand (particularly from the second wave of the pandemic in 2020 onwards)  
b) Higher acuity of patient – in part potentially a consequence of delayed presentation because 
of pandemic  
c)  Growing  levels  of  workforce  absence,  both  because  of  the  Covid  pandemic  and  more 
particularly  the  Omicron/BA2  strains,  and,  increasingly,  because  of  environmental  issues 
triggered by excessive delays at hospitals – the concept of “moral injury”  
d)  Excessive  delays  in  the  handing  over  of  patients  at  hospital,  a  function  both  of  increased 
demand across the system and of the paucity of social care provision (the reasons for which are 
many and various), resulting in, at the time of writing, some 1,200 patients remaining in hospital 
beds across Wales when they are medically fit for discharge. This has led to chronic congestion 
within the hospital system and very poor patient flow resulting in delayed handover of care to 
Emergency Department staff upon arrival of an ambulance and thus delays in response in the 
community.  

Nationally in Wales, 999 call volumes have been increasing, and volumes weekly since October 
2021  have  generally  exceeded  the  levels  of  demand  compared  to  the  previous  three  years 
(please see graphs in supporting data pack).  

Our forecast is currently one where volume continues to exceed previous levels of 999 demand. 
Within this demand are repeat callers who use 999 multiple times because of excessive waiting 
times  in  the  community. We  should  note  that  this  type  of  repeat  call,  often  referred  to  as  an 
Estimated Time of Arrival (ETA) call, is different to those that could be said to be vexatious.  

Since 2019, changes have been noted in demand patterns. There has been a notable increase 
in red demand, which shifts the overall acuity of the calls we receive and puts different pressures 
on resources. Importantly and generally, more resources per red incident are clinically required 
compared to other category of calls.  

As a result, further collaborative modelling has been undertaken by ORH which has confirmed 
that this change requires additional response capacity, specifically in terms of single responder 
/ car capacity. No additional funding has been announced at the time of writing for 2022/23 for 
any further growth in front line response.  

In  addition,  the  COVID-19  pandemic  has  also  had  a  significant  impact,  changing  patterns  of 
demand as the waves have progressed, and changing operational processes (for example the 
donning and doffing of personal protective equipment) which have impacted on response times 
and flow.  

As a service, it is acknowledged that absence rates are unsustainably high though patterns of 
increase do have strong correlation to the waves of the pandemic. The pre-existing Managing 
Attendance Policy for NHS Wales was appropriately adjusted to exclude Covid related absences 
from management action and at the time of writing these arrangements are expected to conclude 
on 30 June 2022. Further, and perhaps as a reaction to the unprecedented delays which staff 
are  encountering  at  hospitals,  rates  of  attendance  are  improving  more  slowly  than  we  would 
ideally like.  

7 

 
 
 
 
 
 
 
 
 
 
 Significant  investment has  been made  over recent  years in  the Trust’s  health and  well-being 
offer for staff, which is now regarded as sector leading.  

This notwithstanding, absence rates remain stubbornly high although these are not out of kilter 
with other ambulance services across the United Kingdom. As a result, an extensive attendance 
management  improvement  plan  has  been  developed  with  a  range  of  measures  aimed  at 
improving attendance and supporting our people back to work.  
However, the “moral injury” reported by staff remains equally high, as the environmental stress 
of working under sustained and relentless pressure takes its toll.  

Much  of  that  “moral  injury”  is  derived  from  the  excessive  handover  delays  at  hospitals  being 
experienced over very extended periods.  

With the entire health and care system under pressure and chronic congestion in hospitals, April 
saw  some  30%  of  the  national  emergency  ambulance  capacity  (Emergency  Ambulance  and 
Urgent Care Ambulance able to transport a patient) rostered to work lost and unable to respond 
to emergency calls as a result of delayed handover of care at hospitals.  

This results in several things: extremely poor patient and staff experience; extended waits in the 
community which result, regrettably, in some patients coming to harm; staff frustration leading 
to  increased  absence  from  work  and  diminished  public  and  stakeholder  confidence  in  the 
service.  

It  is  also  recognised  that  there  may  be  opportunities  within  some  of  the  legacy  operating 
practices for efficiency such as time lost by the Trust’s own crews (post-production lost hours), 
for  example  when  they  return  to  base  for  meal-breaks.  However,  it  should  be  noted  that  on 
average  this  takes  18.5  minutes  on  each  occasion  a  crew  returns  to  station  for  a  rest  break 
which given our extended geography doesn’t present as unreasonable.  

The Trust has been working closely with its trade unions on this, and all of the issues outlined in 
this response, to ensure solutions are identified and delivered in partnership.  

Data specific to the Aneurin Bevan University (ABU) Health Board area are included in the data 
pack, but generally the data for ABU is consistent with the all-Wales picture in respect of growing 
demand, excessive handover delay, acuity, and absence.  

Patient Safety  
It  is a  sad fact  that the  cumulative  effect of the performance  pressures  outlined above has a 
detrimental impact on patient safety.  

There is recognition across the United Kingdom that hospital handover delays cause direct and 
indirect patient harm and a poor-quality service. A recent structured clinical review of handover 
delays England wide was commissioned by the Association of Ambulance Chief Executives and 
published in November 2021. This review highlighted that 8 out of 10 patients waiting over one 
hour were assessed as experiencing some level of harm, with just less than 1 out of 10 patients 
classified as experiencing severe harm. Welsh Ambulance Service NHS Trust –AACE report on 
hospital handover delays: Statement from the Chief Executive (wales.nhs.uk) 

The  Trust  has  an  incident  reporting  and  investigation  process  in  place,  aligned  to  the  NHS 
(Wales)  Regulations  2011.  A 
(Concerns,  Complaints  and  Redress  Arrangements) 
multidisciplinary panel meets at least weekly to review all patient safety incidents assessed as 
potentially  causing  serious  or  catastrophic  harm.  Internal  investigations  are  undertaken  to 

8 

 
 
 
 
 
 
 
 
 
 
 
 
 identify  learning  opportunities  and  improvement  actions  are  subsequently  developed  and 
implemented.  

The Trust is recognised by Health Inspectorate Wales as having a strong culture of reporting 
harm, with serious adverse incidents (SAIs) being reviewed both via the Trust’s Serious Case 
Incident Forum (SCIF) and being reported nationally to Welsh Government.  
A  significant  proportion  of  SAIs  are  also  shared  by  the  Trust  with  health  boards  for  joint 
investigation,  particularly  where  handover  delays/long  community  waits  are  deemed  to  be  a 
pertinent factor in the outcome for the patient and/or their poor experience. Where an emergency 
department  handover  delay  is  considered  a  primary  causation  of  a  SAI/National  Reportable 
Incidents (NRI), the details of the incidents are provided to the Health Board using an agreed 
transfer process known as ‘Appendix B’.  

During  2021  the  NHS  Wales  Delivery  Unit  undertook  an  analysis  of  ‘Appendix  B’  reports, 
submitted by the Trust to the Health Boards. The analysis focused on identifying any trends or 
themes of potential patient harm caused by the Trust’s inability to respond to calls due to NHS 
Wales system pressures. Finding from the analysis included:  

a)  ‘The  most  common  contributory  factor  detailed  in  the  Appendix  B  is  handover  delays, 
where WAST resources  are  delayed  in handing  over patients upon  at  hospital sites in 
keeping with nationally agreed handover timescales’.  

b)  ‘Given that in 71 (84%) of cases the outcome has been death, with the vast majority of 
these deaths occurring prior to WAST, the data indicates that the window of opportunity 
to provide medical assistance to seriously unwell patients in the community, classed as 
Amber 1 calls, is being routinely missed, and likely on the balance of probability to be a 
causative factor in the timing of patients death, given they were alive at the initial call but 
deceased upon arrival 6.5 hours later (on average)’.  

Similarly,  all  Health  Boards  receive  quarterly  reports  on  quality  and  safety  incidents  as  they 
relate to their areas and populations, for whom they have population health responsibility.  

At  the  time  of  writing,  the  issue  of  patient  safety  is very  high  on  the  Board’s  agenda,  with  its 
committees considering in May 2022 a number of papers evidencing harm and expressing their 
concern about the safety of patients in the current operating climate.  

It is the risk to patient safety which is the Trust’s key driver in redoubling its efforts with Welsh 
Government, commissioners and other stakeholders to drive real improvements at pace.  

Healthcare Inspectorate Wales (HIW) undertook an inspection of the Trust and published their 
report ‘Review of Patient Safety, Privacy, Dignity and Experience whilst Waiting in Ambulances 
during  Delayed  Handover’  which  covered  1  April  2020  and  31  March  2021.  The  inspection 
covered  all  Emergency  Departments  (ED)  across  Wales.  Recommendations  from  the  report 
include:  

a)  Health Boards and Welsh Government should consider what further actions are required 
to  make  improvements  regarding  the  patient  flow  issues  impacting  on  delayed  patient 
handover. This may include consideration of whether a different approach is required by 
the Trust, Health Boards, and social care services within Wales, to that taken to date in 
tackling this system-wide problem.  

b)  Health Boards should consider the benefits of the introduction of specific roles within their 
EDs that have the aim of improving process the handover of patients from ambulances. 

9 

 
 
 
 
 
 
 
 
 
 
 c)  Health  Boards  must  ensure  that  appropriate  representation  is  present  at  the  Trust’s 
Serious Clinical Incident Forum meetings, to aid with the timely management of concerns 
and service improvement.  

Following  publication  of  the  Report  the  Emergency  Ambulance  Services  Committee  (EASC) 
recently  set  up  a  task  and  finish  group  chaired  by  the  Deputy  Chief  Ambulance  Services 
Commissioner to respond to the recommendations. The membership of the group is determined 
locally but should as a minimum consist of clinical and operational representatives from each of 
the  7  Health  Boards.  Membership  also  includes  representatives  from  the  Trust  and  Welsh 
Government.  

Addressing the Issues  
It is fully acknowledged that the issues confronting the health and care system are not easily 
resolved.  

That said, the safety of patients is, at differing points, compromised because of system pressures 
and the Board of the Welsh Ambulance Service recognises that this is unacceptable.  

As a result, a number of actions have been put into place to try and mitigate risks to patients, 
with variable levels of success, while wider system and governmental conversations are now in 
an acute phase at the time of writing following escalation by me and other senior officers at the 
Trust.  

Detailed  below  is  a  brief  overview  of  the  actions  which  have  been  taken,  or  proposed  to 
commissioners, by the Trust, in a bid to alleviate the current pressures.  

Resource Escalation Action Plan (REAP)  

The aim of this plan is to describe the arrangements in place to be considered by the Trust in 
response to a strategic or dynamic assessment of pressures affecting or likely to affect service 
delivery. The plan sets out a set of triggers based on various metrics that will identify pressure 
on service delivery and act as a guide to support decision-making. It outlines a categorisation of 
pressure on a scale of 1 to 4 with associated actions for consideration. This categorisation is 
considered and set weekly by a group of senior operations managers. Given many of the actions 
that  can  be  taken  within  REAP  take  some  days  to  take  effect  this  plan  is  designed  to  be  a 
proactive forward looking tool to be used for short periods of additional pressure regardless of 
cause. It is not designed for sustained long term or permanent use at high levels of escalation. 
A copy of the plan appears as Appendix 2 to this statement. 

Clinical Safety Plan  

The Clinical Safety Plan (CSP) provides a framework for the Trust to respond to situations where 
the demand for services is greater than the available resources. It recognises that causes can 
be multifaceted impacting either demand for services, the capacity to respond to demand, or 
both.  

The CSP provides a set of tactical options that are flexible and immediate so that the Trust can 
dynamically react to situations to ensure those patients with the most serious conditions or in 
greatest need according to their presentation remain prioritised to receive services.  

10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 At its core, it achieves this by introducing a principle of ‘can’t send’ so that available capacity 
when  it  is constrained  can  be  targeted at those  who need  it  the most,  which  results  in some 
callers being advised that an ambulance is not available to respond.  

The level of CSP is constantly monitored, and decisions to escalate to higher levels are made 
by  the  Strategic  Commander  and  depending  on  the  level  are  supported  through  clinical  and 
executive consultation. A copy of the plan appears as Appendix 3 to this statement.  

Seasonal planning including forecasting  
As well as utilising the services of ORH in longer term demand and capacity modelling, the Trust 
also commissions services from Optima who use simulation models which can predict output 
performance based on a range of input assumptions.  

Through the pandemic period, the Trust has worked hard to improve its shorter term forecasting, 
and has produced quarterly reports which set out what performance is likely to be, given a series 
of assumptions around demand and available capacity. The accuracy of these reports has been 
good,  and  they  have  been  used  within  the  Trust  and  in  discussions  with  commissioners,  to 
develop mitigating action plans where performance is forecast to be below that required.  

Additional Capacity  

Throughout  the  period  of  the  pandemic,  additional  Urgent  Care  Service  capacity  has  been 
provided  through  an  agreement  with  St  John  Ambulance  Cymru.  This  has  been  financially 
supported by our commissioners wherever possible and concluded at the end of March 2022 
without ongoing financial support.  

To further mitigate the risk significant hospital delays are causing the service, cohorting crews 
provided by a private provider are being used to care for patients delayed outside Morriston and 
the Grange Hospitals while specific funding remains available.  

During  the  periods  of  extended  hospital  handover  delay  that  the  Trust  is  experiencing,  this 
initiative enables frontline crews to offload patients to appropriate clinicians in order for vehicles 
to be available and respond to waiting calls in the community, and ensuring that patients receive 
a more timely response which results in reduced patient safety incidents and improved patient 
experience.  

The  initiative  has  positive  impacts  on  staff  morale,  reducing  the  amount  of  hours  that  crews 
queue outside hospitals and the subsequent well-being concerns that this entails. We have not, 
however, been in a position to deploy such an approach in North Wales, as a result of lack of 
suitable accommodation and financial availability.  

Voluntary  overtime  remains  available  for  all  operational/clinical  staff  across  the  Trust  without 
financial restriction and whilst uptake has reduced in recent months, largely as a result of the 
current  workplace  experience,  we  continue  to  see  in  excess  of  5,000  hours  per  week  being 
worked. Controls to restrict the overall spend on overtime may need to be introduced as the year 
proceeds should the financial position require it.  

Roster review  

The roster review, as agreed as part of the Demand and Capacity Review, has been progressing 
well. The review is being supported by an external company, Working Time Solutions (WTS), 
who are experienced in these reviews across other ambulance services, other public sectors 

11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 and industry. The work has progressed through a series of four working parties in each local 
area, attended by front line staff, managers, resource team and trade union partners.  

The four working parties have now concluded, and it is anticipated that the new rosters will be 
implemented between September and November 2022. As outlined above, by aligning rosters 
more  closely  with  demand patterns, this will  have  the  equivalent  impact  of  an  increase of  72 
WTE.  

The roster review process was paused in 2021/22 whilst additional modelling was undertaken 
to  understand  the  impact  of  the  increases  in  red  demand  and  a  further  decay  in  emergency 
department handover lost hours. The outcome of that modelling was that further single staffed 
car capacity was required, totalling 90 WTE additional staff, and this has now been built into the 
new  rosters.  Commissioners  have  agreed  that  the  modelling  is  correct,  but  no  additional 
resources have so far been made available for 2022/23, which means that the new rosters will 
initially operate with an inbuilt relief gap.  

Roster Review Project – ABUHB 

Increase 

Increase 

Funded  FTE 
(closing the relief gap) 
Unfunded  FTR 
(CHARU) 
Gross  %  Increase  in  Front 
Line Establishment (funded 
and unfunded) 
Net  %  Increase  in  Front 
Line 
Establishment 
(funded) 

53.58 

30.84 

27% 

20% 

Escalation  

WAST Operational Delivery Unit  

The Operational Delivery Unit (ODU) acts as a central hub providing coordination for the Welsh 
Unscheduled Care System with a link between the Trust, Welsh Government, and all the Health 
Boards through a system-wide view.  

The purpose of the ODU is to keep the unscheduled care system in Wales flowing by supporting 
existing internal and external operational management arrangements. It provides a management 
overview of the Trust and broader unscheduled care system delivery by monitoring and reacting 
to real time performance inhibitors that challenge timely and effective patient care.  

The ODU currently has four main areas of focus to achieve this purpose; to maintain pan-Wales 
situational awareness, to consider performance, limit post-production lost hours and plan for the 
upcoming 24 hours.  

Alongside the four areas of focus, the ODU has three main objectives to ensure system wide 
performance.  

a) Pre-empt: Identify and analyse potential risks and issues over the next 24hours and 
current trends  
b)  Mitigate:  With  the  aid  of  local  teams,  develop  actions  to  mitigate  or  negate  any 
identified risks/issues  

12 

 
 
 
 
 
 
 
 
 
 
 
 
 c) React: Dynamically react to situations as they unfold and take decisions on whether to 
react  

System and Peer Groups  

The leadership team of the Trust has taken every opportunity to escalate concerns across the 
system over a period of months 
.  
Professional leads, peer groups, and government have been apprised of the risks, harms and 
challenges  in  various  forums  in  addition  to  formal  reports  and  correspondence,  while 
commissioners have been presented with the same and a currently unsupported Transition Plan 
(see below) to try and ameliorate the worst of the performance issues and attendant harms.  
The  Trust  also  uses  regular  media  and  stakeholder  briefings  to  explain  the  issues,  both  to 
encourage  appropriate  use  of  urgent  and  emergency  healthcare  by  patients  while  ensuring 
stakeholders are sighted on the issues and what is being done to mitigate harms and improve 
performance.  

Similarly,  partnership  groups,  including  Regional  Partnership  Boards  where  the  Trust  is  a 
member,  have  been  apprised  of  the  issues  and  early  conversations  with  local  authorities  in 
particular are progressing (subject to capacity constraints on both sides) to identify collaborative 
opportunities to reduce conveyance and improve the experience of patients.  

Transition Plan  

The Trust is committed to doing all that it can to reduce clinical risk, improve patient care and 
outcomes, ensuring that patients get the right service, in the right place, every time. The data in 
support of this statement  shows  that  there  is  much  more  to  do,  with  some actions  within  the 
Trust’s control, and many which are outside of its control.  

As a result of concerns about clinical risk and patients coming to harm, the Trust developed a 
Transition Plan, which was submitted to commissioners in December 2021. In essence, this plan 
was a bid for investment, as well as setting out the actions to be taken within the Trust to continue 
to improve efficiency and to transform its delivery model.  

The  case  proposed  additional  investment  to  increase  front  line  capacity  by  around  300  FTE 
across the Emergency Medical Service (EMS), including advanced practice paramedics (APPs). 
The proposed investment, building on previous investment, together with the delivery of a series 
of changes and efficiency improvements commenced over the last two years, would provide a 
range of significant benefits:  

a)  an  increased  capacity  and  resilience  in  our  core  service  to  meet  the  needs  of  the 
population  of  Wales  in  a  safe  and  timely  way,  improving  outcomes  for  patients  and 
reducing clinical risk and harm;  
b)  an  improvement  in  the  working  lives  of  our  frontline  staff,  alleviating  the  causes  of 
stress and sickness and further improving our ability to provide the required capacity;  
c)  a  transition  away  from  the  traditional  model  of  ambulance  services,  towards  a 
transformed  state  in  which  patients are  increasingly  treated  at  or near home,  avoiding 
unnecessary  conveyance  to  an  Emergency  Department  (ED),  improving  patient 
outcomes, and relieving pressure within the urgent and emergency care system;  
d) a realignment of resources, ensuring that their value is maximised in the most effective 
and efficient way to meet patient needs.  

13 

 
 
 
 
 
 
 
 
 
 
 
 Significant pressures within the 999 service in the last 12 months have led to very poor patient 
experience and outcomes, with response times lengthening for all categories of patients, and 
too many patients coming to serious harm as a result.  

The Trust has also had to deploy its Clinical Safety Plan more often than it would want, and at 
times, has been unable to send any ambulance response to patients in lower acuity categories, 
adding risk to patients and to other parts of the urgent and emergency care system.  

Despite  the  proposals  being  put  forward  by  the  Trust,  to-date  the  Transition  Plan  remains 
unfunded  although,  at  the  time  of  writing,  discussions  continue  with  commissioners  and 
government.  

Closing Observations  

The pressure facing the Welsh Ambulance Service and the wider health and care system are 
sustained, extreme, and not new. They are issues which have been evident for far too many 
years. 

The recent pandemic and its impact has thrown into sharp relief the fragility of that system and, 
with  competing  priorities  around  urgent,  unscheduled  and  planned  care,  health  boards  and 
government  are  having  to  manage  multiple  issues  at  a  time  when  there  is  limited  capacity, 
energy and resources to drive forward solutions in the quantum required to make a sufficiently 
significant impact.  

All  partners,  whether  in  health  or  social  care,  recognise  that  something  needs  to  be  done 
differently,  and  all  acknowledge  that  patients/clients  are  the  net  losers  in  the  currently 
overheated system.  

As  an  ambulance  service,  we  recognise  that  there  are  issues  within  our  gift  to  resolve  (e.g. 
attendance, post production lost hours) and there are tangible plans in place to address these.  

All these actions, the quantum of which remain insufficient to offset system wide inefficiencies, 
at best demonstrate 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. 

Taken  together,  the  Trust  Board  believes  the  organisation  has  taken  all  possible  steps  to 
manage and mitigate the impact of acute system pressures, including those which are beyond 
our  control  but  impact  on  our  ability  to  respond  in  a  timely  way  or  provide  patients  with  the 
experience they have a right to expect.  

However, there are no easy answers. The key issue will be the pace and urgency with which the 
system  can  respond  to  the  matters  at  hand,  recognising  that,  following  repeated  WAST 
escalation, this is now starting to gain traction.  

While significant collaborative work continues to be undertaken on these issues, there is little 
that the ambulance service can fundamentally do to insist on discrete actions, beyond lobbying 
and  highlighting  the  very  significant  patient  safety  concerns  which  arise,  particularly  from 
extended  waits  outside  hospitals,  which  inevitably  also  result  in  excessive  waits  for  those 
patients awaiting help in the community.  

Similarly, the role of Welsh Government will be considerable both in terms of resourcing and 
policy direction if we are to see the real and tangible shifts away from a hospital and conveyance 

14 

 
 
 
 
 
 
  
 
 
 
  
 
 
 
 model  of  care,  to  one  which  really  focuses  on  upstream  and  community-based  models  of 
integrated care.  

The Trust will continue to press for real systemic change at every opportunity and continues to 
do its very best to deliver a consistent service at a time of significant societal difficulty.  

To conclude, our response to Mr Samuel was not the level of service that we want to provide for 
the people in Wales. I hope that this response has 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 are having on patients in our communities.  

Whilst writing I would like to extend my sincere condolences to Mr Samuel’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  provide  you  with  any  further  assurance  you  may  require  regarding  our  commitment  to 
continual improvement to support the prevention of future deaths.  

Yours sincerely  

Chief Executive 

Encl: 

Action Plan 
Appendix 1 – 3 

15