Vivienne Greener

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Dyddiad / Date: 15th  February 2024 

David Pojur  
HM Assistant Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin LL15 1YN  

Dear Mr Pojur,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Vivienne Greener   

I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 18 
December 2023, issued by yourself to Betsi Cadwaladr University Health Board, following 
the inquest touching upon the death of Vivienne Greener.    

I would like to begin with offering my deepest condolences to Mrs Greener’s family and 
loved ones, and to apologise on behalf of the Health Board for the failings you identified 
in the care provided to Mrs Greener prior to her death in 2018.  

In the notice you highlighted a number of concerns which I have responded to below. 

Your notice was also issued to the Minister for Health and Social Services. The Minister’s 
officials have liaised with my own officers to ensure a coordinated response. I am aware 
the Minister has specifically responded to point nine of your concerns, and I will therefore 
address the first eight points.  

Out of hours emergency endoscopy not available at Clan Clwyd Hospital or in this 
area of North Wales 

Ysbyty  Glan  Clwyd  (YGC)  does  not  have  the  demand  to  support  a  24/7  service  in 
accordance  with  guidelines from  the  National Institute for Health  and  Care  Excellence 
(NICE).  

As you identified, Wrexham Maelor Hospital (WMH) would previously take over patients 
with urgent upper gastrointestinal bleeds, once they were stabilised at YGC. This cross-
site cover has stopped due to workforce challenges at WMH. Currently the clinicians will 
adopt  the  recommendations  set  out  in  the  Upper  GI  Bleeding  –  Management  and 
Principles of Care at YGC ‘pathway. The pathway outlines the following: 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 Optimal  resuscitation  measures,  excellent  major  haemorrhage  management,  close 
critical care monitoring (and use in extremis of the Sengstaken tube for variceal bleeds) 
can stabilise most Upper GI bleeding until endoscopy can be done at the earliest next 
opportunity.  On  very  rare  occasions  when  patients  cannot  be  stabilised,  and  patients 
display  evidence  of  ongoing  life  threatening  bleeding  such  as  overt  large  volume 
bleeding,  haemodynamic  compromise,  shock,  NEWS  scores  >8,  or  high  Glasgow 
Blatchford scores the following key staff should be contacted - the on call Consultant 
Physician, Surgeon, ITU team, and ED consultant  to lead on the management and 
coordinate care.  

Additionally, an instruction to ask switchboard to set up a conference call between the 
ED  consultant,  ITU  consultant  on  call,  consultant  Physician  and  on  call  Consultant 
Surgeon to explore local options in North Wales and reach a joint decision. The detail of 
this process is outlined in the Upper GI haemorrhage protocol and that is due for review 
in April 2024. 

A new Gastroenterologist has been appointed in YGC and will start in April 2024 and they 
will be part of an upper GI rota. 

The provision of out of hours endoscopy services is recognised as a corporate risk for 
the Health Board and is recorded on the risk register, which is reviewed monthly by the 
executive  team  for  any  escalating  clinical  concerns,  or  progress  being  made  against 
submitted business cases for future provision of the service. Any incident of failure, or 
delay, to carry out an endoscopy procedure according to National Guidance (explicit in 
NICE  recommendations)  is  reported  via  the  Datix  system,  and  is  investigated  by  the 
Central Integrated Health Community Senior Leadership team. If necessary, the incident 
will be escalated to the Executive team for consideration of a more senior panel oversight 
to  review  all  treatment  actions  and  decisions  in  a  Rapid  Learning  Panel,  with 
recommendations  for  any  learning  identified  through  this  process.  Provision  of  out  of 
hours endoscopy remains under review given the historical and on-going concerns and 
the teams will be working towards the development of a suitable rota. 

We acknowledge the department is challenged by acuity and service demand, similar to 
other Emergency Departments across the UK.  

The Emergency Department at YGC is fully staffed with junior doctors, in line with the 
budgeted  provision,  and  appropriate  staffing  levels  are  put  in  place  through  rota 
management  each  month,  with  mitigation  in  place  for  management  of  sickness  and 
unplanned absence. In addition, staffing levels have been mitigated with the expansion 
of  Consultant  numbers  since  Mrs  Greener’s  death,  and  there  are  now  8.6  whole  time 
equivalent Consultants plus 1 whole time equivalent locum. Our senior consultants, are 
also  available  24/7  to  attend  to  and  support  cases  such  as  this,  and  all  core  clinical 
consultant shifts are covered.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Emergency Department are continuously reviewing staffing in relation to increasing 
the  core  numbers  to  meet  national  recommendations  within  the  funding  envelope 
available, and work is ongoing to map the resource required to meet demands.   

Nurse staffing for the Emergency Department is calculated on an annual basis using a 
triangulated methodology. Within BCUHB the process of calculating nurse staffing levels 
has three steps: 

Step 1: Initial Review 

Each department completes the designated proforma available within the ‘Nurse Staffing 
Levels (Wales) Act 2016’ Operational Guidance as evidence of the review and application 
of  the  triangulated  methodology.  Once  completed  the  Integrated  Health  Community 
Nurse Director / Associate Director of Nursing leads a review to calculate Nurse staffing 
levels  in  collaboration  with  the  Heads  of  Nursing,  Matron,  Ward  Sister/Manager,  and 
senior  colleagues  from  Finance.    The  review  is  informed  by  both  qualitative  and 
quantitative information comprising of:   

  Acuity data – the overall severity of patient presentations in the department. 
  Professional judgement  
  Quality  Indicators  –  such  as  the  impact  of  staffing  levels  on  the  risk  of  falls, 

pressure ulcers, likelihood of medication errors and complaint 

  Department  environment, layout and geographical position 
  Detail of service and patient pathway changes 
  Unit based initiatives including improvement programmes or action plans 
  Current  nurse  staff  provision  over and  above  core,  (supervisory  ward manager, 
enhanced and advanced practitioners, support workers, ward administrators etc.).   

Step 2: Health Board Wide Review 

A Health Board wide (multi-site, service specific) review is undertaken, led by the Director 
of  Nursing  for  Workforce,  Staffing  and  Professional  Standards,  taking  into  account 
national guidance and best practice evidence, to ensure a consistent Health Board wide 
approach. The review includes sharing good practice and lessons learnt and assurance 
of compliance with the Nurse Staffing requirements in that all workforce models included 
have  an  uplift  of  26.9%  and  a  supernumerary  Band  7  Nurse  in  Charge  has  been 
calculated within the overall workforce plan for each department. 

Step  3:  Formal  Presentation  of  Nurse  Staffing  Levels  to  Executive  Director  of 
Nursing & Midwifery 

Integrated  Health  Community  Nurse  Director  /  Associate  Director  of  Nursing  formally 
present  their  proposed  nurse  staffing  levels  to  the  Executive  Director  of  Nursing  and 
Midwifery and on approval; this is formally presented to the Board.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The current nurse roster template is held in the rostering system and details the number 
of registered nurses and health care support workers on designated shifts. The fill rates 
for these shifts are as below: 

Fill rates denote the staffing levels that should be in place, with 100% being the desired 
staffing. The Registered Nurse fill rate for days and nights during 2023 has been above 
this level. 

The  YGC  ED  department  along  with  the  other  two  sites  are  in  the  process  of  being 
reviewed as part of the 2023/2024 annual nurse staffing review cycle and have they have 
proposed that the current staffing roster template is increased. 

To support sufficient nurse staffing, a twice-daily report is completed electronically on the 
Safe  Care  electronic  system. This records  available  nurses  on  shift.  A  red flag  on the 
system marks any deficit, which is visible by the Matron and Head of Nursing who will 
attend the department to support a review of nurse staffing.  

The YGC Matron of the Day will have information on all nurse staffing across YGC and 
can  reallocate  staff  across  departments  and/or  approve  additional  nurse  staffing  to 
mitigate any risks identified during the daily site system calls which occur three times a 
day.  

The electronic rostering system enables easy identification of any staffing deficits which 
assists  workforce  planning  for  the  nurse  in  charge,  matron  and  head  of  nursing.  All 
temporary  staffing  requests  and  bookings  are  made  via  the  rostering  system.      The 
electronic system will also generate a response that temporary staffing cover has been 
successfully  arranged,  which  is  visible  to  the  nurse  in  charge,  Matron  and  Head  of 
Nursing on the system. From this, all staffing deficits with a red flag identified and leading 
to potential patient harm are reported via the Health Board incident reporting system and 
are reviewed at a weekly meeting led by the Executive Deputy Directors of Nursing, to 
understand  any  ongoing  risks  and  harms  that  may  have  occurred  as  a  direct 
consequence, where IHC Nurse Directors present evidence of mitigation and quality of 
care actions taken against each incident reported. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Space  is  an  issue  due  to  the  increase  in  demand  on  the  Emergency  Department.  On 
average daily attendances range between 130 and 150, however we are experiencing an 
increase in volume to 150 – 180 attendances per day. Furthermore, due to challenged 
bed  capacity  across  YGC,  we  are  experiencing  a  greater  length  of  stay  within  the 
department and on occasions seeing patients with a length of stay between 12-48hrs; 
this creates further congestion within the department.  

Processes are taking place in respect of patient flow to release capacity, however, we 
are  reviewing  the  opportunity  to  create  additional  capacity  in  terms  of  infrastructure 
changes and a review of our current START clinical area. This would create a dedicated 
speciality waiting area with cubicles for review. This scoping is work in progress, and will 
be formalised.  

Ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency 
Department by ambulance 

Within the ED at YGC, the Manchester Triage Tool is in place (which staff have been 
trained  in)  which  highlights  prioritisation  of  patients.  A  waiting  room  member  of  the 
nursing team is in place 24 hours a day, 7 days a week and the triage registered nurse 
and nurse in charge will address stroke, chest pain and silver trauma – this is for walk in 
patients prior to formalised triage assessment. All ambulance handovers are triaged by 
a senior nurse. Triage outcomes and decisions are recorded electronically on Symphony 
system, which is a relatively new system that was introduced on 30th March 2022. 

A clear understanding of when the Emergency Treatment Team should be called 

With  regards  to  understanding  when  to  call  the  Medical  Emergency  Team  (MET), 
evidence  of  the  MET  call  process  is  included  on  the  National  Early  Warning  Score 
(NEWS)  chart  and  is  clearly  visible  to  all  clinicians  assessing  and  reviewing  patient 
recorded observations. For clarity, the Emergency Treatment Team is now known as the 
Medical Emergency Team. 

Use of the National Early Warning Score (NEWS) is a standard approach to assessing 
the acute illness and severity of the individual’s clinical presentation.  

No  clear  understanding  of  when  the  Major  Haemorrhage  Pathway  should  be 
engaged 

Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the 
wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. 
Senior staff who are all very familiar with the pathway are always available and support 
all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the 
pathway.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Upper  GI  Bleeding  Management  and  Principles  of  Care  2022  is  no  longer  fit  for 
purpose 

I can confirm this was updated in July 2023 and will be reviewed again in April 2024. This 
guideline  follows  the  appropriate  NICE  guidelines  and  the  acute  upper  GI  bleed  care 
bundle from the British Society of Gastroenterology. 

Learning  from  the  Health  Board’s  Investigation  Report  is  not  adequately  shared 
with its practitioners 

In  relation  to  your  concern  that  incident  investigation  reports  are  not  shared  with 
clinicians,  I  can  confirm  that  following  concerns  from  other  coroners,  a  new  incident 
process is being developed and will be implemented in April 2024.  

Part of the  Investigation Report changed  in  different  versions  and obscured the 
reason why the provision of blood products was delayed meaning issues are not 
sufficiently identified and actioned 

Finally, regarding your concern that the investigation report changed in different versions 
and obscured the reason why the provision of blood products was delayed, I understand 
,  IHC  Medical  Director  provided  a  statement  regarding  this.  Our  new 
incident process mentioned above will introduce a new  report template making it clear 
which version is the final, approved version of the report avoiding any confusion between 
the final approved version and any draft versions.  

I  hope  this  letter  offers  you  assurance  on  the  action  we  will  now  take  to  ensure  the 
concerns you raised are addressed and that changes are made to our clinical services.  

Once again, I offer my deepest condolences to the family and friends of Mrs Greener for 
their loss. 

Yours sincerely 

Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro 
Executive Medical Director / Acting Deputy Chief Executive  

cc  

, Deputy Director for Quality Governance

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

Mr David Pojur 
Assistant Coroner for North Wales (East and Central) 
Coroner’s Office 
County Hall 
Wynnstay Road 
Ruthin 
Denbighshire 
LL15 1YN 

5 February 2024  

Dear Mr Pojur 

Re: Regulation 28 Prevention of Future Deaths report - Vivienne Greener (deceased)  

I am writing in response to a Regulation 28 Report to Prevent Future Deaths (the report) 
which I received on 18 December 2023, following the conclusion of the inquest into the 
death of Ms Vivienne Greener which occurred on 20 March 2018.  

I would like to offer my sincere condolences to Ms Greener’s family on their sad loss.  

In the report you ask for details of action taken or proposed by the Welsh Government and 
Betsi Cadwaladr University Health Board to improve delivery of services to aid prevention of 
future deaths. 

My response will largely focus upon the ninth matter of concern in the report, regarding the 
timeliness of ambulance patient handover, and the health board will reply on matters of 
concerns 1 – 8.  My officials have worked with the health board to ensure that our 
responses are co-ordinated and consistent. It is important to ensure lines of accountability 
are clear given that responsibility for delivery of services falls with the health board. The role 
of the Welsh Ministers is to set the strategic direction for health boards and NHS trusts and 
to hold them to account for delivery of policy.  

You will be aware that the urgent and emergency care system in Wales, as with other parts 
of the UK, has been under often unrelenting pressure for many years. This is due to the 
challenge presented by an ageing population, increasing prevalence of people with multiple 
chronic conditions and difficulties in supporting timely discharge of patients to local 
communities caused by social care capacity issues.  

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

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.   

 
  
 
 
               
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Patient flow is a key contributing factor to long ambulance patient handover delays. When 
flow is challenged bed occupancy levels increase. This often results in patients waiting long 
periods for admission to hospital from emergency departments and, consequently, limits 
available space for patients arriving by ambulance in the emergency department itself. This 
can cause long ambulance patient handover delays, impacting negatively on patient 
experience and crucially limiting available ambulance capacity to respond to other patients 
in the community.  

These issues are all connected and require long term strategic change. The overarching 
Welsh Government strategy towards enabling management of these issues is set out in A 
Healthier Wales.  

To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations 
of health boards and NHS trusts through an annual NHS planning framework. Organisations 
are expected to produce integrated medium-term plans annually, that respond to the 
priorities set in the NHS planning framework. The planning framework clearly sets out my 
expectation that health boards prioritise plans to improve timeliness of ambulance patient 
handovers to free up ambulance clinicians to respond to patients in the community. Given 
the relationship between both timely patient discharge and ambulance patient handover, I 
have also set a priority for improvement in patient flow.  

To enable health boards and partners to deliver against these priorities, I established a 
national urgent and emergency care improvement programme in April 2022 and, in support, 
have made £50m in additional funding available over the past two years. I directed each 
health board to develop a local programme plan that incorporated actions to improve 
ambulance patient handover performance and patient flow, among other local priorities.  
Progress has been made across a number of indicators in recent months to help reduce 
pressure on emergency care services and to release capacity for patients who need an 
immediate response: 

• 

• 

Urgent Primary Care Centres in north Wales are treating around 2,300 people a 
month, reducing pressure on GP in-hours services and emergency departments;  
•  We have funded extensions in capacity for same day emergency care services which 
are treating and discharging hundreds of patients per month across the three district 
general hospitals in north Wales, freeing up precious bed capacity;  
The NHS 111 Wales telephone service has been rolled out nationally and now 
receives 70,000 calls a month helping to limit avoidable attendances at emergency 
departments;  
The ‘111 press 2’ service is now available in every health board area in Wales, 
providing urgent mental health support to people of all ages 24 hours a day 7 days a 
week. Over 38,000 callers have accessed the pathway, with 56.4% receiving self-care 
advice / no further action needed. 99.1% of people who call in distress report lower 
levels of distress following the call.  Over 6,000 calls have been received in the Betsi 
Cadwaladr University Health Board area which have been answered and provided with 
appropriate triage;  

• 

•  We have targeted investment in 999 ambulance clinical triage resources and 

technology. This includes the use of video consultation technology. Around 4,500 (10-
15%) patients across Wales per month are now managed without needing transport to 
an emergency department;  

•  Welsh Government provided £3m to the Welsh Ambulance Service in 2022 to recruit 
100 new staff, and also provided funding for a pilot delivered by St John Ambulance 
which is supporting around 50% of people referred to the service to safely avoid 
transport to hospital; and 

 
 
 
 
 • 

An additional 21 full time equivalent (FTE) Welsh ambulance staff have been added in 
the Betsi Cadwaladr University Health Board area since December 2021, an uplift of 
4.7%.  

In addition, I directed the Chief Ambulance Services Commissioner to monitor delivery of 
plans intended to secure improvements through Emergency Ambulance Services 
Committee governance mechanisms. The Committee, made up of the seven chief 
executives of health boards, agreed to work towards eradicating all handover delays over 
four hours in length by the end of 2024/2025.  

In terms of progress, we have generally observed improvements in ambulance patient 
handover although I remain extremely concerned about timeliness of handover in general 
and particularly at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.  

In view of my concern, all health board chief executives were directed to prioritise three 
actions for delivery over the winter months as part of a new NHS Wales ambulance patient 
handover improvement plan implemented from the festive period 2023/2024. As part of their 
local plan, the Betsi Cadwaladr University Health Board priority actions include:  

•  Maximising the use of same day emergency care pathway across all acute sites to 

• 

• 

reduce pressure on emergency departments. 
A focus on reducing delayed discharges into the community through the Pathways of 
Care Delays project, to release hospital capacity earlier and support improved patient 
flow. 
Implementation of a continuous flow model at Wrexham Maelor to support improved 
patient flow through the site, enable timelier handover of patients from ambulance 
vehicles and release crews to respond to other patients in the community.   

Although the winter period and the associated difficulties has been and will be challenging 
for NHS organisations, I expect to see improvement and will be monitoring the situation very 
closely over the coming weeks and months.  

Turning to strategic plans to support improvement in quality of care in emergency 
departments. I continue to support improvements in emergency departments through a 
range of measures and this year will publish a Quality Statement for care within the 
emergency departments, setting out my expectations for the service. To deliver this, we are 
bringing the voices of our clinical leaders together through the newly established Strategic 
Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters 
most to people who use the service. I made over £500,000 of additional funding available to 
Betsi Cadwaladr University Health Board in December 2023 to support upgrades and 
improvements in their emergency departments which will enhance both patient and staff 
experiences in waiting rooms. 

In terms of how the Welsh Government holds health boards to account for delivery of timely 
ambulance patient handover, this is done through a range of mechanisms:  

• 

• 

I hold health board chairs to account for delivery and have incorporated ambulance 
patient handover improvement as a key objective for all chairs for 2023/2024. I 
consistently seek assurance from chairs as a collective on their organisations’ 
commitment to making improvements through regular national meetings.  
There are established national mechanisms for monitoring the quality, safety and 
effectiveness of services provided by health boards across Wales. Assurance is 
sought and challenge provided on a regular basis regarding ambulance patient 
handover performance, through ‘integrated quality, planning and delivery (IQPD)’ 
meetings between Welsh Government, the NHS Executive and NHS organisations. 

 
 
 
 
 
 
 • 

These are held monthly in addition to ‘Joint Executive Team (JET)’ meetings held 
every six months.  
Information from a range of processes and partner organisations about ambulance 
patient handover performance and related issues, including reviews conducted by the 
NHS Executive and others, have and continue to feed into these assurance 
mechanisms.  

Yours sincerely,  

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