Lynda Blackmore

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

26 May 2023  

Ms Joanne Kearsley  
Senior Coroner for Manchester North  
HM Coroner’s Court 
Floors 2 & 3 Newgate House  
Rochdale  
OL16 1AT 

Dear Ms Kearsley,    

Re: Regulation 28 Prevention of Future Deaths Report (Sienna Daisy Barber)  

I write in response to your regulation 28 report dated 3 May 2023 regarding the very sad death 
of Sienna Daisy Barber. I would like to express my sincere condolences to Sienna’s family.   

We have reflected on the circumstances surrounding Sienna’s death and the concerns raised 
in your report. We note your concerns about the lack of guidance to diagnose and treat group 
A streptococcus infection specifically, and your request that NICE develop guidance on this 
subject.   

We have produced several guidelines to help clinicians treating children presenting with fever 
and  symptoms  such  as  those  in  the  case  of  Sienna.  These  include;  fever  in  under  5s: 
assessment  and  initial  management  [NG143],  sepsis:  recognition,  diagnosis  and  early 
management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].  

Group A streptococcus is not mentioned specifically in these guidelines as the diagnosis and 
early  management  of  children  presenting  with  fever  is  similar  whatever  the  underlying 
pathogen. It is expected that these guidelines are considered when people presenting with 
symptoms like Siena’s are assessed in primary and secondary care.   

The recommendations in our guidelines represent the view of NICE, arrived at after careful 
consideration of the evidence available. When exercising their judgement, professionals and 
practitioners are expected to take our guidelines fully into account, alongside the individual 
needs,  preferences  and  values  of  their  patients  or  the  people  using  their  service.  It  is  not 
mandatory to apply the recommendations, and the guidelines do not override the responsibility 
of  healthcare  professionals  to  make  decisions  appropriate  to  the  circumstances  of  the 
individual, in consultation with them and their families and carers or guardian.  

 
 
 
 
 
 
  
  
  
 
 In addition to our guidance, there are also Clinical Knowledge Summaries (CKS) published on 
our website on the related topics of scarlet fever and sepsis. The CKS are developed by an 
external company called Agilio Software and are designed to summarise the evidence on the 
treatment of specific health conditions, however, they do not constitute NICE guidance and 
are not mandatory. 

We have not yet been asked to produce a guideline on group A streptococcus specifically. 
Topics for the NICE work programme are referred to NICE by the Department of Health and 
Social  Care,  NHS  England  and  other  government  departments  in  line  with  the  national 
priorities that they have established.       

As you have said in your report, we have also published diagnostic guidance on rapid tests 
for group A streptococcal infections in people with a sore throat [DG38]. We were unable to 
recommend the tests for routine adoption for people with a sore throat. This is because their 
effect on patient outcomes as compared with clinical scoring tools alone, and their potential 
effect on antimicrobial prescribing and stewardship, is likely to be limited.  

The  diagnostic  guidance  also  highlights  that  children  under  5  should  be  assessed  using 
NICE's guideline on fever in under 5s: assessment and initial management and people who 
are at higher risk of complications, for example women who are pregnant or who have just 
had a baby, or people who are immunocompromised, should be offered antibiotics in line with 
our guideline on antimicrobial prescribing for acute sore throat.   

Finally,  as  you  will  be  aware,  NICE  is  not  the  only  organisation  that  produces  clinical 
guidelines, and we would also expect that there are local policies and care pathways that are 
followed in individual hospital trusts.   

I hope this response has helped outline our role and the guidance we have produced in this 
topic area.   

Yours sincerely, 

Chief Executive     

                                                                                                                                 Page | 2

Our ref: NP/GJ/kh 

Thursday 11th  January 2024 

Bwrdd lechyd Prifysgol 
Aneurin Bevan 
University Health Board 

Mr Graeme Hughes 
Senior Coroner South Wales Central 
Coroner's Office 
The Old Courthouse 
Courthouse Street 
Pontypridd 
CF371JW 

Dear Mr Hughes 

Regulation  28  Report  received  by  Aneurin  Bevan  University  Health  Board  further  to  the 
inquest touching on the death of Lynda Blackmore which concluded on 1 November 2023 

Thank you for your letter of 15 November 2023 and accompanying report, which the Health Board 
received on 17 November 2023. 

I am writing to provide you with the Health Board's response to the Regulation 28 Report to Prevent 
Future Deaths, which was issued following the inquest into the death of Lynda Blackmore. 

You  have advised,  via  your letter,  that your concern is that handover delays are impacting  upon 
response times in respect of patients requiring emergency treatment and/or conveyance to hospital 
and  that in  your opinion,  action  should  be taken  by the  Health  Board  to prevent future  deaths in 
regard to Mr Andrew Garner's witness statement, in particular paragraphs 43 -49. 

As requested, the information presented below is intended to describe the actions which have been 
taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths: 

1.  Paragraph  43 - 45  The Trust  (WAST)  was  experiencing  hospital  handover delays  in  the 

Aneurin Bevan University Health Board area. 

2.  Paragraph 46 - The response to Mrs Blackmore was 13 hours. 

W ith regard to the first point,  it is acknowledged that the Health Board was experiencing handover 
delays at all of its sites on this day. During the previous days all hospitals within the Health Board 
and indeed, neighbouring Health Boards experienced delays that were in excess of the 15 minutes 
standard as stipulated in the Welsh Health Circular (May 2016). 

Bwrdd lechyd Prlfyssol Aneurln Bevan 
Pencadlys, Ysbyty S.Ont cadog 
Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 
\. 01633 436 700  f BwnldlechydPrllyJIDI  X BIPAn•urln-n 
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-....~--yo,-~-....,.,-~--

IS2J Clinigol 

Clinical

Aneurln Bevan University Health Board 
Headquarters, St Cadoc's Hospital 
Lodge Road, caerleon, Newport NP18 3XQ 

'-01633 4l6 700  f  Anou<lnlnanHeohhBoard X AneurlnBevonUHB

--""""'Y--G..__d ___ la__  

Wtwtbrre~inWlllfl"MVlllmpcrdinWf#lwilto.tdillty

 
 
 
 
 
 
 
 
 
 
 
 
 
 The days leading up to the incident on 1 February 2023 saw very high attendances at the Grange 
University Hospital {GUH) with activity on  31  January 2023 one of the highest during January (270 
attendances)  which  placed  significant  additional  pressure  on  services,  particularly  within  the 
Emergency Department (ED). As can be seen from the table below, there was significant pressure 
seen  from  29  January  to  1  February,  with  average  handover  being  in  excess  of the  15 minute 
standard;  this  was  also  reflected  in  the  cumulative  daily  lost  hours  (the  time  recorded  from  15 
minutes onwards for each ambulance patient handover). 

Gran1e University Hospital 

Date 

Dolly Activity 

Ambulance 
Arrivals 

29.01.2023 
30.01.2023 
31.01.2023 
01.02.2023 

268 
252 
270 
248 

BO 
63 
68 
69 

Av11ragtt 
Handover 
Time 
119mins 
105mins 
80mins 
121 mlns 

Lost Hours 

109 
91 
64 
116 

Red&Amber 
Rttlttase 
Requms 
2 
3 
2 
0 

The Division of Urgent Care had managerial and operational responsibility for the ED at the GUH at 
the time of this incident. The management team have had a number of processes in place to improve 
flow. Therefore, the pressures at the front door and leadership on a day-to-day basis for GUH was 
managed  by the  Corporate  Site  Operations  Team  who  ensured  that  where  delays  were  being 
experienced  that the  Health  Board's  'Emergency  Pressures  Escalation  Policy'  is  actioned.  This 
document  provides  clarity  on  the  responsibilities  of  a  wide  range  of  Health  Board  colleagues 
including  the  Emergency  Department,  Operational  Site  Managers,  Senior  Divisional  Leadership 
Teams and Executive Directors and that actions that must be taken to reduce ambulance delays, in 
particular, and system pressures. 

Since this incident, a  review of the Health  Board's Divisional  structures have been  strengthened, 
with the Division of Urgent Care now assuming full responsibility for the Corporate Site management 
team  to ensure  a full  and  co-ordinated  focus  is  maintained  on  safe  patient flow  and  ambulance 
handover delays. 

Other initiatives have seen the introduction of weekly Patient Safety Flow meetings during May 2023, 
chaired by the Deputy Director of Operations with input from the Executive team including the Chief 
Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. 
These  meetings focus  on  the delivery and  performance  of the  Health  Board's ED  and  MIUs with 
very clear action plans to  mitigate the  risk  and  seek improvements in  patient flow and  ambulance 
handover delays.  The focus has been on the following areas: 

1.  Pre-Hospital / Flow Centre.  Due to the unique nature of the Clinical Futures model that 
the  Health  Board  manages,  a  Flow  Centre  is  operated  to  ensure  that  all  ambulance 
admissions  (excepting  life  threatening  emergencies)  and  admissions  received  from 
General Practitioners are screened to ensure that the patient is referred and streamed to 
the correct hospital and department.  Further actions within this workstream include: 
a.  Consultant presence in the Flow Centre to aid senior clinical decision making 
b.  Redirection  for  specific  conditions  to  eLGH  sites  rather than  the  GUH  for  more 

appropriate and rapid assessment and treatment 

c.  Falls response in the community 

2.  Emergency Department/Assessment Area Focus 

a.  Revision of the escalation framework to ensure that the points of escalation during 

any ambulance handover delays are appropriate 

b.  Creation of inter-speciality standards 
c.  Prioritisation and assessment of the balance of risk 

2 

 3.  Discharge Logistics 

a.  Focussing  on  how  the  Health  Board  can  better  utilise  its  discharge  lounges to 
provide an immediate and early pull from wards across all sites to create capacity 
to support ambulance handover times 

b.  Improving how the internal process for the handover of patients who are transferred 

from the GUH to the eLGH sites 

The Health Board is also fully engaged with the NHS Wales Six Goals for Urgent and Emergency 
Care programme which has been co-designed on a national basis by clinical and professional leads. 
Spans  the  urgent and  emergency  care  pathway  and  reflects  the  priorities  in  the  Programme  for 
Government 2021  - 2026 to provide effective, high  quality and  sustainable healthcare as close to 
home as possible, and to improve service access and integration. The expectation is that adoption 
of nationwide best practice,  including a local input into specifics will improve handover delays and 
reduce clinical risk. 

The individual goals and workstreams that have also been instrumental in the reduction in handover 
delays within the Health Board since February 2023 the Six Goals priorities have been streamed in 
to three distinct workstreams and includes: 

1.  Workstream 1 - Redesigning Services for Frail and Older People 

a.  Development of a permanent acute frailty team to focus on this cohort of patients 
b.  Redesign of the model for community hospitals including Direct Access beds 
c.  Extending the Community Resource Team offer to support people with complex needs 

within the home 

d.  Work with WAST on a Virtual Ward Model 
e.  Greater support to Care Homes 

2.  Workstream 2 Urgent & Emergency Care Redesign 

a.  Improvements to the Same Day Emergency Care (SDEC) services established within 
GU H and  YYF  Hospitals,  increasing  patient selection which will  release  capacity for 
ED and  Assessment Units. These services have seen a continued  upward trajectory 
in medical patients since March 2023. 

b.  Continuing  of WAST's  'waiting  stack'  reviews and  continuing  redirection  of patients 
where deemed clinically safe and appropriate Improvements in WAST access to the 
Health Board's Flow Centre 

c.  Single  phone  number for  health  care  professionals  to  enable  a  smoother  contact 
process with alternative services including community frailty and Urgent primary Care 
d.  WAST referral  line for agreed alternative to ED  pathways within the Health  Board to 
prevent direct ED attendances Initial scoping and commitment from the Health Board 
and  WAST  to  create  a  collaborative  working  workstream,  specifically  looking  at 
alternatives to hospital conveyance: 

e.  Review of Ambulatory Care pathways including respiratory and chest pain pathways 
Improvements  in  community falls  including  head injury and  fractured  neck of femur 
f. 
pathways 

g.  Pilot of an Electronic Triage system within the ED and MIU department waiting rooms 

to improve efficiency and risk management. 

3.  Discharge Improvement to support more timely discharge and supporting people back to 

their own homes thereby reducing urgent and emergency care delays 
a.  Introduction of focussed patient safety events across all the key Health Board sites to 
improve discharge processes and number of patients waiting in hospitals for discharge 
to either home or another facility 

b.  Creation of a discharge hub at the Royal Gwent Hospital jointly with social care 
c.  Creation  of a Ready to Go Ward  and  a discharge floor at the Royal  Gwent to  bring 
together a discharge lounge, the Ready to Go Ward and in integrated hub to manage 
patients transition more effectively to their own home 

d.  Creation  of  a  Hospital  to  Home  service  to  provide  additional  support  within  the 

community 

3 

 e.  A focused project at Nevill Hall Hospital working with  Monmouthshire Local Authority 

focused on proactive discharge arrangements to people's own homes 

Regarding  the  second  point,  whilst  the  response  to  Mrs  Blackmore  was  13  hours,  it  was 
acknowledged by WAST that an ACA2 crewed ambulance could have attended to her and conveyed 
should one have been available to do so.  An ACA2 staff member has a skill set that is  below that 
of a  Paramedic or Emergency Medical Technician  but does have the ability  to  monitor,  treat and 
convey patients that  are within  their scope  of practice.  The  Health  Board  operates  an  Inter Site 
Transfer Service (ISTS) comprising a maximum of 10 ACA2 crewed ambulances at peak times. This 
service was commissioned from WAST specifically to support the Clinical Futures model's required 
transfers in and out of the Grange University Hospital. 

WAST do have the ability to utilise these vehicles for a community-based response Band do so on 
a  regular  basis,  this  would  have  been  an  appropriate resource  to  meet  Mrs  Blackmore's  needs. 
However, on this occasion, this was not requested or actioned. The Health Board understands that 
there were  twenty occasions between  14:56 on  1 February 2023  and 01 :39 on 2  February 2023 
where  one  of  the  Health  Board's  ISTS  ACA2  ambulances  could  have  been  allocated  to  Mrs 
Blackmore's amber two category 999 call and this did not happen. 

Finally, I would wish to reassure you that the Health Board is rigorously focused on the reduction of 
patient handovers and  the associated  risk for patients that these delays create.  In  addition to the 
focused work referenced above the Chief Operating Officer and the Clinical Executives are providing 
leadership and challenge to addressing this important issue and  it is a personal ambition as Chief 
Executive that we eradicate these delays as soon as we practically can.  I trust that this information 
reassures you about the Health Board's plans to improve ambulance handover delays.  However, if 
you  require any further information or assurance, please do not hesitate to contact me. 

Yours sincerely 

Prif Weithredwr / Chief Executive 

4

Ymddlriedolaeth GIG 
Gwasanaethau Amblwlans Cymru 

Welsh Ambulance Services 
NHS Trust 

Cade1rydd 

Prif We,thredwr

Swyddfa'r Prif Weithredwr a'r Cadeirydd 

Chair and Chief Executive's Office 

04 January 2024 

PRIVATE & CONFIDENTIAL 
For the attention of Mr Graeme Hughes 
Senior Coroner 
South Wales Central Area 

Dear Mr Hughes 

Re:  Mrs Lynda Blackmore 

I am writing in response to the Prevention of Future Deaths Report issued to this Trust on the 9 
November 2023, following the inquest. 

The matters of concern that you have asked the Trust to consider are:-

"The  investigation  focused upon  the  causal significance,  if any,  of a delay of some  thirteen 
hours,  or thereabouts in  the provision of an ambulance to the deceased. 

 of the  Welsh  Ambulance Service 
I received written &  oral evidence from 
Trust (I annex a copy of his witness statement).  I refer you in particular, to paragraph's 43-
49. 

My concern here is that handover delays are impacting upon response times in  respect of 
patients requiring emergency treatment & for conveyance to hospital. As
in  his evidence  at para  45,  the  handover delays  experienced at/around the  time  that the 
deceased was awaiting assistance were well in excess ofthe targets enshrined in the Welsh 
Health Circular of May 2016. 

Mae'r Ymddiriedolaelh yn croesawu goheb,aeth yn y Gymraeg 
neu·r Saesneg, ac na fydd gohebu yn Gymraeg yn arwa n at oed, 

The Trust welcomes correspondence in Welsh or English. and 
that corresponding in Welsh will not lead lo 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 

 
 
 
 
 
 
 Such delays pose a risk to the lives ofthose requiring emergency treatment/conveyance to 
hospital." 

At this time and in specific response to this Prevention of Future Deaths Report, the Trust does 
not propose to take any further action or new actions in relation to this matter, but rather continue 
with the actions in  place. There has been a noticeable improvement in Cardiff & Vale University 
Health Board's handover lost hours linked to an organisational focus, with other Health Boards 
reporting that they are seeking to learn lessons. 

The table  below illustrates  the  improvements that have  been  made  by the  Health  Board  and 
Trust  in  order to  reduce  hours  lost whilst ambulances  are  delayed  at  hospital.  The  table  is 
extracted from the  Monthly Integrated Quality & Performance Report and was presented to the 
Trust board on 23 November 2023. 

Am b el"  Median Response Times against Handover lost Hours 

35000 

30000 

?S000 

20000 

15000 

10000 

0 

I 

'"'' 
t'"!f 
iri' 

'}'  ~  ~ ...... 
~ <'-I 
~ i=  ~ .6 
"' 

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I 

03:50:24 

03:21:36

02:52:48 

02:24:00 

01·26:24 

00:57 36 

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0-

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I 00:28.48

00:00:00 

-

-

SB Lost I-lours 

-

AB Lost t-tOUl'S 

CTM Lost 1-iours 

HD Lost Hours 

-

-

UOJ LOst Houis 

Powys 

-

-

I 
C&V Lost Hours ' 

AMBER MC!dian 

Whilst these improvements have been seen with hospitals in the Cardiff & Vale University Health 
Board area the Trust is aware that ambulances delayed at hospital in neighbouring Health Board 
areas can also have an  effect on those resources in the Cardiff & Vale University Health Board 
area. 

This is because the Trusts Clinical  Response Model adheres to the  dispatch principle that we 
seek to send the nearest most appropriate resource in time waiting order. Therefore, if because 
of ambulances delayed at hospital, the nearest most appropriate resource is in a  neighbouring 
Health Board area, then this resource will be dispatched. 

2 

 The  details  illustrated  below  shows the  total  number of cases  where  resources  based  in  the 
Cardiff & Vale  University  Health  Board area  have responded to patients  outside of the  Health 
Board area due to ambulances delayed at hospital.  A total of 5865 between Jan '23 and  Nov 
'23. This  is broken  down to 3542 resources going into Aneurin Bevan University Health  Board 
area and 2284 into Cwm Taff Morgannwg University Health Board area. 

EMS Cross Boundary Responses 

- - - - - -

Oale f'lliod: 

OIAll/2022 

lo 

,.,-lit 

11 
JI 

MIS 

10 

1• 

I 

25 

Cardiff and Vale - Cross Boundary Responses 

Cardllhnd Vole 
EA 

'31 

1700 

122 

21-

1101 
2m 
211 

3000 

2000 

1500 

1000 

500 

A<,..,,;,, e..... 

Btlli ca.i..aladr  Owmlal Morgannwg 

Hywol Dda 

CMofMa 

SwansaaBay 

The details illustrated below shows the total  number of responses returning  into Cardiff & Vale 
University Health Board area from Aneurin Bevan University Health Board area (2747) and from 
Cwm Taff Morgannwg University Health Board area from Aneurin Bevan University Health Board 
area (2284). 

EMS Cross Boundary Responses 

llllel'lliod: 

01•14112 

ID 

30/11/2023 

....  _.., 

32 
:It 

.. 

IN! 

Ja 
14 
M 

:1111 

" 

Aneurin Bevan - Cross Boundary Responses 

............. 

EA 

H)lorlO. 

OOl ol-

211111 
1711 

15 
ztlt 

2000 

1500 

1000 

500 

Cardiff and VIII 

OwmTafMorgannwg 

HywtfDdo 

Oul oflvea 

Powys 

- ... eay 

This final table and graph show the number of resources from Cwm Taff Morgannwg University 
Health Board into Cardiff & Vale University Health Board area (1688) and Cwm Tat Morgannwg 
University Health Board area into Aneurin Bevan University Health Board area (1278). 

3 

 -- -=•:.;;; 

219 
,m 
105 

:zee 
1!15 

70 

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EA

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11• 

IJII 

EMS Cross Boundary Responses 

- -

-

-

- - - - - - - -

Dale Pwiod: 

01Al1rio22 

ID 

30/1"2023 

20 

1' 

JT 

40 

)2 

Ill 

111' 

111

1' 

74 

-

CwmTai Mofgannwg - Cross Boundary Responses 

1000 

Ii  =eoo1  J J

i  £00 

600

'Ii 

20G 
o • 

'----'--

_J 

~ - -- - - - - - - -~-

Cardilf andV1't 

Hywo!Oda 

Outo/Aru 

~  - -- -- - -- - - -
P""fl 

Swan1tallay 

This  clearly  shows a  higher proportion  of vehicles  going  out of the  Cardiff &  Vale  University 
Health Board area into the other Health Board areas. 

Aneurin Bevan University Health Board have nearly double the Emergency Ambulance capacity 
at  peak,  than  Cardiff &  Vale  University  Health  Board,  with  Aneurin  Bevan  University  Health 
Board  having  22 Emergency Ambulances  at peak against  13 in  the  Cardiff & Vale  University 
Health Board area at the same time. 

The  Trust  is  taking  all  possible  steps  within  its  control  to  ensure availability  of resources  to 
respond to Red and Amber calls.  The Trust also seeks to secure full support from the Welsh 
Government,  the  wider  NHS  and  the  local  Government  to  ensure  appropriate  clinical  risk 
management across the urgent and emergency care pathways to release resources to the Trust. 
The Trust has evidenced this work through the comprehensive details of all the actions that we 
have taken to date. 

I  attach  for your reference  copies of the  Real-time  Mitigation  Report,  Reducing Patient  Harm 
Action Plan and the Associated Risks,  all of which were presented to the public Trust Board on 
23rd  November 2023.  These documents are regularly presented to, and reviewed by, the Trust 
Board and I hope this offers you assurance that this matter continues to remain a significant risk 
and a matter of attention to the full Trust Board. 

Whilst the Trust fully supports the  need  to  issue  a  Prevention  of Future Deaths  Report under 
Paragraph 7,  Schedule 5 of the Coroners & Justice Act 2009 and Regulation 28 and 29 of the 
Coroners (Investigations) Regulations 2013, we do not believe that we are the authority with the 
"power to take such actions".  Notwithstanding the authority to act, I have recently held executive 
level meetings with Aneurin Bevan University Health Board colleagues and as a result of these, 
we have agreed some additional measures that we will be implementing in January 2024.  These 
measures are expected to reduce the number of conveyances to The Grange Hospital through 
direct admission to alternative sites and the  introduction of a new temporary facility that can be 
used for patients who are often those that experience the longest delay in handover.  We expect 
both these measures, in  addition to those outlined in our responses to date, to offer additional 
support to the release of ambulances back into the community for response. 

To reaffirm  my earlier comment, we believe we have robust plans in  place which are regularly 
critiqued and  monitored throughout the organisation.  The issues arising  are  presented  to our 
full  Trust Board  and  we  liaise  directly with the  Health  Board and  wider health  and  social care 

4 

 partners across Wales in order to secure their support to ensure that we  respond  to  Red  and 
Amber calls in a timely way. 

While writing  I would  like to  offer my sincere condolences to  Mrs. Blackmore's family on their 
sad loss.  I would also like to extend an offer to meet with you and  leaders of key organisations 
to discuss our response in more detail, and to provide you with any further assurances you may 
require regarding our commitment to continue improvement to support prevention of harm and 
future deaths. 

Yours sincerely 

Chief Executive 

Enc:  Real-time Mitigation Report 

Reduced Patient Harm Action Plan 
Associated Risks 

5