Maria Whale

lxecutive Headquarters  /  Pentadly!>  Gweithredol

Woodland House 

T\'  Coedt,r 

Maes-y-Coed Poad 

Ffordd Mae-s-y..: OE-::1 

Cardiff 

Caerdydd 

GIG  Caerdydd a'r Fro 
04-./IONHS  Cardiff and Vale 

Bwrdd lechyd Prifysgol 

University Health Board 

A. 
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Eich ,yf/Vov, rtf; AM 17541 

E,n cyf/Ovr rtf; SR·jt·0722·9664 

Wtlst, Hutti-. Ttlt~l,ot1t Nttwo,1:: 

28th  December 2022 

Re:  Maria lmmocalata Whale 

Dear Dr Richards, 

Thank you for your Regulation 28 Report dated 141

~ November 2022. 

In response to the inquest evidence and the concerns you consider a risk of future deaths, I have 
reviewed Maria's triage and management by the Out of Hours GP Service. I thought that it may be 
helpful to share with you the initial findings. 

I was concerned that this was not appropriately communicated with you at the inquest hearing and 
it may be that the poor communication on our part, had led to some of the recommendations in 
your regulation 28 letter. 

Initial contact was made by Mr Whale at 01:58, whereby the call handler took a broad summary of 
Maria's presenting complaint and demographics. The triage priority would have been assessed 
utilising the information imparted by Mr Whale, the decisions template deemed the call non-urgent 
which assigned a 60-minute call back. 

An attempt was made to call the land line, but the line was engaged. 

 contacted Mr 

Whale at 03:13. The appropriate advice was given to call 999 for an ambulance for conveyance to 
UHW because Joanne recognised Maria was gravely unwell and her immobility meant there was no 
other way to transfer Maria to hospital, other than by an ambulance. 

From review of the calls it is clear that all possibilities for transference to EU were explored. 

It is noted that
taken pain relief 20 minutes earlier and had a hot water bottle. 

 did ask during the call whether Maria had taken any pain relief. Maria had 

I have attached a copy of the call transcription for reference. 

Thank you for your kind consideration. 

Yours sincerely,

Ymddlriedolaeth GIG 
Gwasanaethau Amblwlans Cymru 

Welsh Ambulance Services 
NHS Trust 

Swyddfa'r Prif Weithredwr a'r Cadeirydd 

Chair and Chief Executive's Office 

11  January 2023 

PRIVATE & CONFIDENTIAL 
Dr S J Richards 
Assistant Coroner for South Wales Central 

Dear Dr Richards, 

Re:  Maria lmmocalata Whale 

I  am  writing  in  response  to  the  Regulation  28  Report  that  you  issued  to this  Trust,  dated  9 
November 2022, following the sad death of the late Mrs Maria lmmocalata Whale. 

In the Regulation 28 you highlighted your concerns in relation to: 

"The 999 Emergency Service triage patients for priority depending on the response provided by 
a person close at hand to the patient,  to a series of scripted questions.  The  Welsh Ambulance 
Service Trust has advised the following: 

•  Red calls are the highest clinical priority and are deemed immediately life threatening e.g. 

cardiac arrest; 

•  Amber  1  calls  have  a  high  clinical  priority  and are  still  considered a  life  threatening 

emergency e.g.  chest pain; 

•  Amber 2 calls have urgent clinical priority, are serious but not considered immediately life 

threatening, for example diabetic problems; and 

•  Green  calls are  not considered to  have  urgent clinical priority and are not considered 

serious or life threatening. 

Mae·r Ymdd riedoleeth yn croesawu gohebiaeth yn y Gymraeg 
neu'r Seesneg, ec na fydd gohebu yn Gymreeg 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.nhs.wales 

Anfonwch unrhyw 
ohebiaeth i'r cyfeiriad 
canlynol:-

Please forward any 
correspondence to the 
following address:-

Beacon House 
William Brown Close 
Llantarnam 
Cwmbran NP44 3AB 
FfOn/Tel 
01633 626262 

 
 
 
 
 
 Mr.  Whale in responding to these questions was advised his wife was not a priority.  Clearly, 
the  triage questionnaire did not adequately measure the gravity of Mrs.  Whale's condition, 
as within two hours of being graded a 'non-priority' she was declared life extinct.  ". 

I  do  not wish to  repeat the information that was already supplied to you  within  the statement 
from 
.  She  explained  that  the  Medical  Priority  Dispatch  computer  based 
prioritisation System ('MPDS') is not considered to be a triage or diagnostic tool. 

The scripted questions are asked to establish the patient's condition at the time of the call. This 
allows the Trust to attend first to the sickest patient, at that time. 

At the end of each call, the caller is advised to call the Trust back, should the patient's condition 
change. This allows the Trust to reprioritise the patient should their condition improve or worsen. 

At this time the Trust does not intend to adjust the prioritisation questioning, as the issue  is not 
so much the appropriateness of the questions but rather the harm caused by the Trust not being 
able to respond in a timely manner. 

At such times MPDS is supported by the Resource Escalation Action Plan and the Clinical Safety 
Plan. 

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 of1  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. 

2 

 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. 

Background 
I am pleased to be able to provide you,  below, with details of the actions that have been taken 
in  order to  reduce the  lost hours  and  improve  our response  times  to  patients  waiting  in the 
community. I have also attached the most up to date action plan (Reducing Patient Harm Action 
Plan) Appendix 4. This plan has been presented and discussed at the organisation's Trust Board 
meetings since July 2022. 

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 4,000 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 have, over several 
years,  recorded  Prevention  of Future  Deaths reports and other recommendations in respect of 
health services across Wales, including the Welsh Ambulance Service (the Trust). 

Such recommendations are taken extremely seriously by the Trust Board.  In spite of the efforts 
made,  there  is  an  acknowledgement  that  progress in  stabilising  and  improving  ambulance 
service response times in Cardiff & Vale Health Board area, and indeed across Wales 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. 

3 

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

4 

 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 offull 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 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 
pertormancelongterm. 

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 2021/22. 

Performance Pressures 
There are several factors in combination which have led to the significant pertormance 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 the pandemic 

c)  Growing  levels  of  workforce  absence,  both  because  of  the  Covid  pandemic,  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 

5 

 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 
I car capacity. 

In addition, the COVID-19 pandemic 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. Following the pandemic, 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. 

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. 

6 

 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, 
October  2022  the  Trust  saw  some  36%  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  Cardiff  &  Vale  Health  Board  area  are  included  in  the  data  pack,  but 
generally the data for this Health Board area is consistent with the all-Wales picture in  respect 
of growing demand, excessive handover delay, acuity, and absence 

That  being  said,  our  colleagues  in  the  Cardiff  &  Vale  Health  Board  have  undertaken  a 
significant, and impactful, amount of work to address the issues facing both organisations, and 
we  are  seeing  a  marked  decrease  in  the  time  our vehicles  are  at hospitals,  allowing  us  to 
respond to people in the community in a more timely manner. The Trust will continue to work 
closely with our colleagues to build on these improvements. 

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) 

7 

 The Trust  has  an  incident  reporting  and  investigation  process  in  place,  aligned  to the  NHS 
(Concerns,  Complaints  and  Redress  Arrangements) 
(Wales)  Regulations  2011.  A 
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 
identify  learning  opportunities  and  improvement  actions  are  subsequently  developed  and 
implemented. 

The  Trust  is  recognised  by  Health  Care  Inspectorate  Wales  as  having  a  strong  culture  of 
reporting harm,  with  Nationally Reportable Incidents (serious incidents) (NRls) being reviewed 
both  via  the  Trust's  Serious Case  Incident Forum  (SCIF) and  being reported  nationally to the 
NHS Wales Delivery Unit. 

A  significant  proportion  of  NRls  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  /National 
Reportable Incidents (NRI), the details of the incidents are provided to the Health Board using 
an  agreed  transfer process  known  as  the  Joint  Investigation  Framework,  formally  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. Findings 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 Trust Board's agenda, with 
its committees considering a number of papers evidencing harm and expressing their concern 
about the safety of patients in the current operating climate. I have attached the most up to date 
action plan (Reducing Patient Harm Action Plan). This plan has been presented and discussed 
at the organisation's Trust  Board  meetings  since  July 2022  and  most  recently  in  November 
2022. 

8 

 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 Care 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. 

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  Trust  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. 

9 

 Detailed below is a brief overview of the actions which have been taken (in addition to the REAP 
and CSP mentioned earlier in  this letter) or proposed to commissioners, by the Trust, in a bid to 
alleviate the current pressures. 

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 worked  hard to improve its shorter term forecasting, 
and 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. 

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. 

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 now concluded. 
The review was supported by an external company,  Working Time Solutions (WTS), who are 
experienced  in  these  reviews  across  other  ambulance  services,  other  public  sectors  and 
industry.  The  work  progressed  through  a  series  of four  working  parties  in  each  local  area, 
attended by front line staff, managers, resource team and trade union partners. Roll out of the 
new rosters commenced  in September 2022. 

10 

 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, totaling 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 - C&V 

FTE Staffing as at time that 
the Demand and Capacity 
Review (including 
Paramedics, EMTs and ACA2 
staff) 

FTE staff currently 
(paramedics and EMTS only) 

Estimated FTE ACA2. staff 
currently being recruited (end 
of January 2023) 

Total estimated FTE staffing 
by end of January 2023 

Uplift 

149.3 

146.96 

36.83 

183.79 

34.49 
FTE 
(23%) 

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. 

internal  and  external  operational  management  arrangements. 

The purpose of the ODU is to keep the unscheduled care system in Wales flowing by supporting 
existing 
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. 

11 

 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 

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. 

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 The case  proposed  additional  investment to increase front line  capacity  by around  300  FTE 
across the  Emergency  Medical Service  (EMS),  including  Advanced  Paramedic  Practitioners 
(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 existing service provision to meet the needs 
of the population ofWales 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. 

Undertaking  the  above  actions are  principally based  around  protecting  the  services  ability to 
respond  to  patients  whose  presenting  condition  require  a  timely  ambulance  response,  by 
ensuring that as many patients as possible are managed in a setting away from secondary care. 

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, 

13 

 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 
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  Mrs Whale is 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,  waiting  for 
ambulances over an extended period. 

Whilst writing I would like to extend my sincere condolences to Mrs Whales's husband and wider 
family on their sad  loss.  I would also like to extend  the  offer to meet with you to discuss our 

14 

 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 

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