Dorothy Jones

Eluned Morgan AS/MS 
Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol  
Minister for Health and Social Services 

Caroline A. Saunders 
Senior Coroner for Gwent 
Gwent Coroner Service 
The Civic Centre 
Godfrey Road 
Newport 
South Wales 
NP20 4UR 

Dear Caroline 

Re: Mrs Dorothy Anne Jones 

20 March 2023  

Thank you for your letter of 20 January, in which you enclosed a copy of a Regulation 28 
Prevention of Future Deaths report following the conclusion of the inquest into the death of 
Mrs Dorothy Anne Jones. 

Firstly, I would like to take this opportunity to offer my sincere condolences to Mrs Jones’ 
family on their loss. 

The Welsh ambulance service exists to deliver life-saving interventions and take patients 
promptly to hospital, but the pandemic, recent periods of unprecedented pressures and 
challenges with patient flow have had a massive impact on emergency care services across 
all parts of the UK.   We recognise that, at times, demand has outstripped capacity and that 
this has resulted in long delays, and poorer experiences and outcomes for some patients.  
However, the vast majority of patients are receiving timely access and safe care. 

I note you have also written to 
Services Trust and I would expect him to respond on the detail of the concerns you raised 
as these relate to operational matters and are best addressed by the Trust. I can, however, 
outline the actions being taken by the Welsh Government to drive national and local 
improvement in the delivery of safe and timely ambulance services. 

, Chief Executive of the Welsh Ambulance 

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:  
0300 0604400 
Gohebiaeth.Eluned.Morgan@llyw.cymru 
               Correspondence.Eluned.Morgan@gov.wales 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
gohebu yn Gymraeg yn arwain at oedi.  

We welcome receiving correspondence in Welsh.  Any correspondence received in Welsh will be answered in Welsh and corresponding 
in Welsh will not lead to a delay in responding.   

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 We have made significant investment in urgent and emergency care this year, with a 
dedicated budget of £25m annual funding to support local, regional and national delivery of 
the Six Goals for Urgent and Emergency Care, our five-year strategy published in February 
2022, to drive a whole-system transformation of access to urgent and emergency care.  In 
2022/23 each health board in Wales received up to £2.96m to support implementation of 
local ‘six goals’ improvement programmes, and £4m has been used to support nationally-
coordinated projects. 

A national Six Goals for Urgent and Emergency Care Programme has been established to 
secure improvements across the patient pathway, with a specific focus on patient flow 
through the hospital system and out into the community, as well as significant investment in 
urgent primary care and same day emergency care to help reduce pressure on 999 services 
and emergency departments. A direct paramedic referral to same day emergency care 
services pathway has also been developed to enable suitable patients to by-pass the 
emergency department and gain direct access to the most appropriate clinical destination 
for their needs. 

I have been encouraged by progress against a number of key urgent and emergency care 
indicators which has been influenced by the ‘six goals’ programme and I will provide a 
detailed update to Members of the Senedd on the overall urgent and emergency care 
programme plan a year on from its implementation on 2 May, when I will also confirm plans 
for 2023/2024 intended to help people access the right care, in the right place, first time. 

We have also made investments in ambulance services, including £3m funding made 
available in June 2022, to support delivery of a national ambulance improvement plan 
developed by the Emergency Ambulance Services Committee and approved by health 
board chief executives. The plan included a range of actions for delivery by the Welsh 
ambulance service, health boards and actions for joint delivery, to enable better 
management of 999 demand in the community, increased ambulance capacity and 
improved timeliness of ambulance patient handovers.  

Thanks to our early investment, the Welsh ambulance service has been able deliver a range 
of actions to increase capacity including: 

• 

Implementation of new triage and video consultation technology, supported by 
£250,000 Welsh Government funding, to support more confident decision making by 
paramedics about whether a patient needs to be taken to hospital.  This has enabled 
WAST to increase the number of 999 patients who can be safely managed through 
remote telephone assessment, enabling people to receive the support they need in 
the community and freeing up ambulance resources to respond to other calls.  In 
January, 15% of patients were safely assessed and discharged over the phone. 

•  The Welsh Ambulance Services Trust has recruited 380 new staff in the past 9 

months, which includes filling vacancies and increasing its overall headcount and will 
help to future-proof its workforce. 

•  The Trust has confirmed it has completed the implementation of new staff rosters for 
emergency medical services (EMS), marking the end of a two- and half-year project 
including 146 rosters, 80 working parties, and 1,800 staff. The efficiencies associated 
with the new rosters will equate to 72 whole time equivalent staff. The project will 
now be evaluated to support longer-term benefits realisation and learning. 

•  We have also seen progress from the Trust in delivering the agreed workforce 

efficiencies which are helping to increase capacity, including a reduction in sickness 
absence, supported by an attendance management programme and 40-point plan. 

 
 
 
 
 
 
 
 
 •  Discussions between the Trust and its trade union partners regarding further 

workforce efficiencies are ongoing. 

The national ambulance improvement plan has also seen all health boards develop local 
ambulance handover improvement plans, many of which have been in place since August 
2022, which include a range of actions to help increase flow, improve patient experience 
and outcomes, and free up ambulance capacity to respond to urgent calls in the community.  
Health boards have also committed to handover improvement trajectories for each of their 
major emergency departments with an initial focus on eradicating delays over 4 hours and 
reducing the average number of minutes ‘lost’ per ambulance arrival on a monthly basis.   

On 28th November 2022, I hosted a national summit on improving the timeliness of 
ambulance patient handover, which was attended by more than 40 senior NHS Wales 
representatives from across the seven health boards and the ambulance service.  At the 
summit, health boards set out the range of actions they are taking across the six goals for 
urgent and emergency care as well as actions targeted at reducing ambulance handover 
delays.  They also reaffirmed their commitment to delivering urgent improvements ahead of 
the winter, in line with local handover improvement plans and the national ambulance 
improvement plan.  My officials continue to track progress and impact against the 
commitments health boards and the ambulance service have made and I have been 
encouraged by the examples of improvement at a number of sites, most notably the 
University Hospital of Wales. 

Following this summit, and building on the progress made in delivering the actions from the 
national ambulance improvement plan and local handover improvement plans, EASC has 
agreed new integrated local improvement plans with each health board and WAST.  These 
plans started to come into place from November 2022 and contain commissioning 
intentions, priorities and performance improvements and the operational plan to support 
delivery across the breadth of local six goals for urgent and emergency care programmes.  

Regular performance and monitoring meetings held by EASC with each health board will 
drive delivery of these improvement plans and my officials will continue to seek assurance 
on delivery against these plans through regular Integrated Quality, Planning and Delivery 
(IQPD) meetings with each health board, WAST and EASC. 

I have been somewhat encouraged by the improvements in the timeliness of ambulance 
patient handover, and in response times for Red and Amber calls, since we saw record poor 
performance in December 2022.  January 2023 saw a reduction of more than 25% in the 
number of ‘ambulance hours’ lost to handover delays across all Welsh health board areas, 
when compared to December, and national ambulance handover performance in January 
represented the best performance since August 2022. This has had a positive impact of 
ambulance performance nationally, including a significant improvement in the median 
response time for Amber calls in January, which was in fact the fastest since May 2021. 

These improvements must, however, be considered in the context of a reduction in demand 
in January, likely in relation to a change in public behaviours instigated by media coverage 
of NHS pressures and industrial action. It is also evident that performance has not improved 
in all parts of Wales and I have been clear with all Health Boards in my expectations that 
they must work together, and with the Welsh ambulance service and partners to understand 
local, regional and national challenges and agree collaborative actions to ensure patients 
within their communities receive safe and timely access to assessment and treatment and 
ensuring ambulance crews are available to respond when needed, through a whole system 
approach. 

 
 
 
 
 
 
 
 
 I understand 
response in more detail and to provide further assurances regarding the Trust’s commitment 
to ongoing improvement. 

 has extended an offer to meet with you to discuss the Trust’s 

Yours sincerely,  

Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol  
Minister for Health and Social Services

Cadeirydd 

Prif Weithredwr 

Swyddfa'r Prif Weithredwr a’r Cadeirydd  

Chair and Chief Executive’s Office 

17 March 2023 

PRIVATE & CONFIDENTIAL 
Ms Caroline Saunders 
Senior Coroner for the Area of Gwent 

Dear Ms Saunders 

Re: Mrs Dorothy Anne Jones 

I write in response to the Prevention of Future Deaths Report issued to this Trust on 20 January 
2023, following the inquest in relation to Dorothy Anne Jones. 

You have asked the Trust to consider 4 specific areas: 

1.  The steps being undertaken on a national and local level to address the delays in 

ambulance response times, particularly within the Amber 1 category. 

The Trust has focused on actions to mitigate real time avoidable harm and has sustained 
reporting to our Trust Board on progress. Attached is a copy of the progress report, with 
accompanying  action  plan,  provided  at  the  open  Trust  Board  in  January  2023.  As 
recognised, the pressures are multifactorial but none as significant as those connected 
with  patient  flow  leading  to  emergency  department  handover  delays.  These  delays 
remain  elevated  with  more  than  32  thousand  hours  lost  to  extended  handover  in 
December 2023 amounting to 37% of our conveying resource capacity. In January 2023, 
this will be between 23-24 thousand hours which remains extremely high.  

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.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 
Ffôn/Tel  
01633 626262 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Whilst too early to indicate sustained improvement, as levels of activity abate (particularly 
that connected to respiratory illness) there has been improvement in the Amber 1 median 
response  time  in  January  2023  compared  to  the  proceeding  period.  The  Trust  will 
continue  to  report  progress  against  the  actions  to  mitigate  avoidable  harm  to  its  Trust 
Board.  

2.  Whether  consideration  can  be  given  to  undertaking  a  more  detailed  clinical 
assessment of the patients within Amber 1 to ensure those in the greatest need for 
clinical intervention are given priority. 

To ensure that the Welsh Ambulance Services NHS Trust (WAST) maintains a clinically 
safe  response  to  patients,  regular  reviews  are  undertaken  of  current  Medical  Priority 
Dispatch  System  (MPDS)  code  categorisation  by  the  Clinical  Priority  Assessment 
Software (CPAS) group.  

During reviews, each individual code is considered, in terms of the types of patients who 
should  be  within  that  category,  as  well  as  historical  data  on  call  volume,  conveyance 
rates, adverse incidents, and where available, data on success rates of secondary triage, 
etc. The codes are also compared to the categorisation within the Ambulance Response 
Programme  (ARP).  These  are the  categorisations  used  by  the  Ambulance  Services  in 
England. 

In the live environment, WAST regularly undertakes more detailed clinical assessments 
of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the 
correct priority for patients. This process, known as secondary triage or consultation is 
led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control 
room nurses, paramedics, advanced paramedics, and mental health practitioners.  

The  process  of  secondary  triage  or  consultation  involves  clinicians  assessing  patients 
remotely  using  clinical  decision  support  software  over  the  phone  or  through  video 

2 

 
 
 
 
 
 
 
 
 consultation. WAST has recently invested in the CSD by near doubling its establishment, 
employing  mental  health  practitioners,  and  by  implementing  a  new  innovative  clinical 
decision support system to support the more detailed clinical assessment of patients.  

WAST  has  also  invested  in  new  versions  of  its  Computer  Aided  Dispatch  (CAD)  tool, 
which  allows  health  board  Doctors  to  log  in  (remotely  from  the  control  rooms)  to  the 
waiting ambulance stack and undertake more detailed clinical assessments of patients in 
their  health  board.  The  Physician  Triage  Assessment  and  Streaming  (PTAS) model  is 
now operating across three of the health boards with plans to roll out further.  

3.  The process for reassessment of the patient’s clinical condition during the time 

they are waiting for an ambulance. 

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. 

A copy of the CSP is attached for your reference and as you will see this provides details 
of when welfare calls should be made. These calls are made to reassess the patient’s 
clinical condition, if any changes are reported. 

Additionally, the CSP provides details of the actions to be undertaken by the clinicians 
working on the Clinical Support Desk. 

The CSP operates alongside the Clinical Support Desk Standard Operating Procedure 
(SOP), which also documents the actions to be taken by clinicians when there are long 
waits for patients. The SOP provides details of the action’s clinicians on the CSD can 
take with regard to upgrading the call. 

4.  Confirm whether the national algorithm adopted by WAST is fit for purpose and 
that there is provision to identify life-threatening scenarios, where a patient may 
quickly deteriorate from an Amber 1 into a Red. 

The Trust uses 5 priority categories for emergency calls. As per the evidence provided at 
the inquest, these are known as Red, Amber-1, Amber-2, Green-2, and Green-3. Whilst 
the  terminology  is  different  to  other  UK  ambulance  services  (For  example,  English 
services use 5 priority categories, known as Category 1 through to Category 5), but the 
principles of prioritisation, and the vast majority of calls within each category are similar 
across other UK services.   

The utilisation of the Trust’s resources is undertaken in line with our Clinical Response 
Model.  Within  that  model  calls  are  generally  responded  to  chronologically,  within  their 
priority category. So, it is broadly accurate to say that, for example, Amber-1 calls waiting 
for a response are generally responded to in chronological order within the priority, as 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 based  on  available  information  from  the  999  calls.  Again,  this  is  in  keeping  with  the 
principles used by all other UK ambulance services. 

The  staff  responsible  for  the  allocation  of  the  resources  can  allocate  resources  out  of 
chronological  order  and  this  is  documented  in  the  attached  Standard  Operating 
Procedure - Action Cards for Emergency Medical Dispatch. 

However, when the Trust is unable to respond as quickly as we would like to be able to, 
waiting 999 calls (in all priorities/categories) are subject to clinical scrutiny by the Clinical 
Support Desk (CSD). 

Clinicians from the Clinical Support Desk review waiting calls and will speak directly to 
999 callers and/or the patient to establish if other methods of response might be suitable, 
and  to  ensure  the  priority  assigned  to  the  call  does  not  need  to  be  adjusted.  These 
clinicians can change the priority of any 999 call, increasing it or decreasing it, according 
to the outcome of their more detailed clinical triage. 

Whilst writing I would like to extend my sincere condolences to Mrs Jones’ 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 
continual improvement to support the prevention of future deaths. 

Yours sincerely 

Chief Executive 

Enc:  
APP1 - Trust Board January 2023 Action Plan to Mitigate Avoidable Patient Harm 
APP2 - Clinical Safety Plan v2.1 December 2022 
APP3 - Clinical Support Desk SOP Version 1.6 FINAL 19.5.22 
APP4 - Action Card Set For Emergency Medical Dispatch SOP (EMD) V 7 

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