Jean Thomas

gofalu am ein gilydd, cydweithio, gwella bob amser 
 caring for each other, working together, always improving 

           Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg.  
We welcome correspondence in Welsh or English. 

Dyddiad / Date:  29th April 2024 

ALED GRUFFYDD  
Assistant Coroner,  
Swansea, Neath & Port Talbot 

Dear Mr Gruffydd, 

Re: Regulation 28 Response: Mrs. Jean Thomas 

Thank you for providing the Health Board with an opportunity to respond to your concerns 
raised at the conclusion of the inquest of Mrs. Jean Thomas, on 29th February 2024. 

At the outset I would wish to send my condolences to Mrs. Thomas’ family.  Mrs. Thomas’ 
experience following her fall at home on 13th December 2022, is not one that we want for 
any  patient,  and  I  am  sorry  that  delays  in  her  transfer from  home  to  hospital  resulted  in 
harm. 

As  referenced  in  your  inquest  conclusion,  the  challenges  in  accessing  emergency  care 
experienced by Mrs. Thomas are not unique to Swansea Bay University Health Board or 
the wider health system within both NHS Wales and NHS England.  The Health Board fully 
recognises  this,  and  it  is  reflected  in  our  Health  Board  Risk  Register,  with  Access  to 
Unscheduled Care Services being scored at a risk score of 25 (the highest possible). The 
Health Board Risk Register is reviewed at a Board level on a monthly basis. 

It is fully accepted by the Health Board that if we fail to provide timely access to unscheduled 
care then this will have an impact on the safety of patients and the quality of care we provide, 
as  well  as  patient  and  family  experience.    However,  opportunities  to  change  the  way 
services are delivered and the introduction of community-based prevention initiatives are 
being implemented with an aim to reduce harm, such as that experienced by Mrs. Thomas. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters,  
One Talbot Gateway, Port Talbot, SA12 7BR 
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 Since  receipt  of  your  Regulation  28  outcome  letter  the  Health  Board  has  commenced  a 
programme  of  targeted  intervention,  supported  by  Welsh  Government,  to  address  risks 
associated with urgent and emergency patient pathways at Morriston Hospital. The aim of 
this programme of work, which is at an early stage, is to critically review and redesign across 
community access, service delivery, staffing models and infrastructure in order to reduce 
risk. 

All patients arriving at the Morriston Hospital Emergency Department by ambulance, with 
the exception of pre-alert patients who need immediate clinical intervention, go through a 
REACT  process.    The  Rapid  Emergency  Assessment  Care  Team  assess  the  patient  in 
order to identify their needs and this review includes identification of pre-existing pressure 
injuries, assessing risk of deterioration of any existing injuries and the risk of acquiring a 
new pressure injury.  The aim of the assessment is to enable  treatment/prevention to be 
started immediately.  Sadly, during periods of significant unscheduled demand there may 
be  occasions  where  following  REACT  assessment,  patients  have  to  be  returned  to  the 
ambulance due to a lack of space in the Emergency Department.  This was the case for 
Mrs.  Thomas  when  she  arrived  at  Morriston  Hospital  in  December  2022.   Whilst  on  the 
ambulance, patients continue to be monitored by the Emergency Department. 

There is ongoing work in conjunction with the Welsh Ambulance Service to address  how 
pressure relieving equipment can be used on ambulances, both in transit and in situations 
where patients are unable to be handed over from the ambulance crew to the Emergency 
Department Team. The  Health Board has proactively  shared  with  the Welsh  Ambulance 
Service  comprehensive  risk  assessment  documentation  relating  to  the  use  of  pressure 
relieving  mattresses  which  are  able  to  be  used  on  ambulance  trolleys  since  2021  (and 
subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts 
in NHS England, who have adopted the use of pressure relieving equipment in ambulance 
vehicles  (using  Swansea  Bay’s  risk  assessment)  have  shown  a  significant  reduction  in 
healthcare acquired pressure injuries of up to 30%.  

The Emergency Department at Morriston Hospital maintains the ongoing offer of providing 
pressure relieving equipment to the Ambulance Service (25 mattresses available), to date 
this offer has not been accepted. 

The  national  target  for  ambulance  handover  is  15minutes.  Currently  the  Health  Board 
actively monitors ambulance handover performance against the following two performance 
measures: 

  Number of ambulance handovers greater than 1hour  
  Number  of  lost  hours  as  a  result  of  delayed  ambulance  handovers  greater  than 

15minutes 

Performance against these two targets for the 12months, 01/04/2023 to 31/03/2024 is: 

  8,161 ambulance handovers greater than 1hour (average 680 per month) 
  43,453 lost hours in delayed handovers greater than 15minutes 

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 2 

 
 
 
 
 
 
 
 
 
 In November 2023, a “zero” tolerance to ambulance off-load delays, in excess of 10 hours, 
was introduced, at Morriston Hospital. The introduction of this tolerance is part of a reduction 
trajectory  to  improving  handover  times  and  achieving  the  15-minute  target.    However, 
despite improvements in this area, continued pressures on the unscheduled care system 
has resulted in delays over 10 hours still being experienced by patients. 

The majority of delayed ambulance handover events do not result in a significant harm to a 
patient. This is largely due to the REACT risk assessment described above. In the rare case 
when  a  patient  does  incur  a  significant  harm,  a  Duty  of  Candour  process  is  triggered; 
notified  to  the  patient  and/or family  and  a full  investigation  undertaken  with  the  outcome 
provided in line with “Putting Things Right” (2011) Regulations.  

The Health Board recognises that older patients presenting at the Emergency Department, 
with an acute injury will often have additional needs related to frailty.  In September 2024, 
a  dedicated  Frailty  Unit  is  due  to  open  at  Morriston  Hospital.    The  Unit  will  have  direct 
ambulance access and senior clinical decision-makers to ensure that patients are placed 
on the correct clinical pathway at the time of arrival at hospital.  In addition to in-hospital 
pathways, out of hospital pathways, such as “Virtual wards” are also available to ensure 
that patients can access acute care but have a clear plan to get them home when they are 
fit enough to do so. 

I am confident that the operational response to these events means that there is a focused 
effort on finding a resolution to each individual handover delay, which considers individual 
patient needs and their immediate safety.  In some cases, this will include a risk assessed 
additional patient within the Emergency Department. 

I would also like to take this opportunity to focus on prevention of falls as a key factor in 
reducing the demand on acute services.  The Health Board has identified prevention of falls 
as a key quality priority with a focus on both reducing in-hospital falls and preventing falls, 
from occurring within the community requiring acute admission.   

The following key workstreams have been developed: 

1.  “Bay  Watch”  is  an  in-hospital  falls  prevention  initiative  to  reduce  falls  through  co-
production  with  our  patients.    Supporting  them  to  make  the  right  decisions  about  their 
mobility whilst in hospital. 

2.  Launch of the Regional Falls Prevention Taskforce – this brings 3rd sector, emergency 
services, health and local authority together to look at falls prevention in the community 
and feeds directly into the National Falls Prevention Taskforce. 

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 3 

 
 
 
 
 
 
 
 
 
 
 3.  Safe  Care  Collaboration  with  Improvement  Cymru  have  looked  at  response  to  non-
injurious falls at home and within supported living accommodation, residential homes and 
nursing homes, utilising the “iStumble” digital application and multi-agency falls prevention 
training.    The  initial  project  has  seen  a  75%  decrease  in  ambulance  call  outs  for  this 
category of fall event allowing ambulance services to focus on patients who have acute 
injuries. 

4. 

5. 

6. 

 Use  of  “Dance  to  Health”  which  is  an  evidence-based  falls  prevention  programme 
available  in  Swansea  Bay  Region  to  encourage  older  people  to  maintain  strength  and 
mobility.    The  Health  Board  are  currently  sourcing  additional funding  for  expansion  this 
initiative across other sites/regions. 

Introduction  and  awareness  of  Podcast  Series  available  on  YouTube  –  discussing 
everyday  fall  prevention  strategies  and  highlighting  some  taboo  subjects  –  these  are 
publicly available. 

Intergenerational Falls Prevention Programme focusing on the fall incident scene – now 
linked  with  the  National Taskforce.   This is an  educational support  pack available  to  all 
schools  to  educate  and  support  children  and  families  about  falls  prevention  within  their 
wider family. 

7.  The  Health  Board  Falls  Improvement  Lead  is  currently  undertaking  a  scoping  exercise 
commissioned by the Regional Partnership Board, looking at providing a fuller offer of 
community falls prevention services. 

In conclusion, I hope that you are assured that the Health Board is taking a holistic, proactive 
approach to the issues encountered by patients such as Mrs. Thomas, in an effort to reduce 
the risk of any future deaths, as a result of delayed access to emergency care following an 
acute fall event. 

Yours sincerely, 

INTERIM CHIEF EXECUTIVE OFFICER 

 caring for each other, working together, always improving 

gofalu am ein gilydd, cydweithio, gwella bob amser 

Page 4

Swyddfa’r Gwasanaethau Ambiwlans Cymru 
Welsh Ambulance Services Office 

25 April 2024 

PRIVATE & CONFIDENTIAL 

Mr. Aled Gruffydd 

Assistant Coroner 

Dear Mr Gruffydd 

Re: Jean Thomas 

I write in response to the Prevention of Future Deaths Report issued on 4 March 2024, following the 
inquest. 

The matter of concern that you have asked the Trust to consider is:- 

There was a significant delay in getting an ambulance to Jean which resulted in a pressure 
sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be 
offloaded into hospital. The time taken to offload was in excess of 16 hours, when the target 
offloading time is 15 minutes, 

I would like to focus my response to reflect two distinct issues, firstly the issues surrounding delays 
in responding to our patients in community and the delays at hospital, and secondly the work being 
undertaken by the Trust in relation to pressure damage prevention or reduction. 

Firstly at this time, the Trust does not propose to take any further action or new actions in relation 
to the matter of ambulance delays in arriving with patients and patients delayed outside of hospitals. 
The Trust is taking all possible steps within its control to ensure availability of appropriate resources. 

Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg 
neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi 

The Trust welcomes correspondence in Welsh or English, and 
that corresponding in Welsh will not lead to a delay 

www.ambulance.wales.nhs.uk 

Pencadlys Rhanbarthol 
Ambiwlans  

Regional Ambulance 
Headquarters 

Beacon House 
William Brown Close  
Llantarnam, Cwmbran 
NP44 3AB 

Ffôn/Tel  
01633 626262 

 
 
 
 
 
 
 
 
 
 
 
 
 I do not propose to share with you all the historic actions that have been taken by the Trust, should 
you wish for more detail please let me know and the Trust will gladly share with you the actions 
already taken. I propose to concentrate on the actions currently being taken.  

The  Trust  also  seeks  to  secure  full  support  from  Welsh  Government,  the  wider  NHS  and  local 
Government to ensure appropriate clinical risk management across the urgent and emergency care 
patient pathways to release resources to respond in the community. 

Within the enclosures  I have  shared the measures that are currently in place, namely the Clinical 
Safety Plan and the Regional Escalation Action Plan to manage resources at times of high demand. 
I am also attaching copies of the Real-time Mitigation Report and the Reducing Patient Harm Action 
Plan, along with the associated risks, all of which were presented to the Public Trust Board on the 28 
March 2024. These Reports 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 for the Trust Board. 

We believe we have robust plans in place which are regularly critiqued and monitored throughout 
the organisation. The issues arising are presented to our Trust Board and we liaise directly with the 
Health Boards and wider health and social care partners across Wales in order to secure their support 
to ensure that we respond calls in a timely way. 

Secondly, I would like to share with you that the Trust has implemented a range of actions to mitigate 
as much as possible the effects of long community waits and the identification and mitigation of 
pressure damage.  These include: 

•  E-learning programme where causes, risks and identification are explored. 
•  Clinical notices (04/2020, 07/2021, 10/2022) including escalation of concerns at hospital sites. 
•  Trust position on the use of the repose mattress which was shared as not being fit for purpose 

for our stretchers following review. 

•  Review of other services approach and search for specific pre-hospital clinical equipment 
•  Discussions with Stryker who manufacture the stretchers and wider NHS leads on the risks to 

patients and possible solutions. 

•  Updates of certain Medical Priority Dispatch System codes (those patients who have been on 
the  ground  for  more  than  an  hour)  now  include  the  ability  to  automatically  dispatch  our 
community volunteer and falls response teams. 

     Additionally, the focus for Trust clinicians: 

•  High 

index  of  suspicion/inquiry 

into 

the 

risk  of  pressure  area  development 

(frailty/immobile/long lies). 

•  Assessment and identification of high-risk areas. 
•  Repositioning. 
•  Escalation of concerns/risks/harm. 

Despite these actions there continues to be incidents where harm through pressure damage have 
been reported. 

 
 
 
 I  am  pleased  to  share  that  the  Trust  has  been  working  with  an  industry  partner  to  develop  and 
innovate around the current challenge. A company called OSKA have helped us design and test a 
surface that can be quickly deployed onto the Trust’s fleet to help reduce the risk that we are facing 
of increased patient harm by way of pressure damage. 

Pressure  relieving  devices  are  widely  accepted  methods  of  preventing  and  reducing  pressure 
damage development.  There are many different devices used across health and care system but no 
bespoke option has yet been developed for pre-hospital care teams. 

The Trust and OSKA have been working together to develop a bespoke alternating pressure mattress 
that fits the Stryker stretcher.  The Stryker and all ambulance stretchers are designed to support the 
care  of  a  wide  range  of  patients  with  differing  clinical  presentations,  including  those  patients 
requiring cardio-pulmonary resuscitation.  Due to these reasons the mattresses are not designed as 
a  low  pressure  surface.    The  Trust  has  been  in  discussion  with  Stryker  and  there  are  no  plans  to 
change the current design or to adjust the specification to meet the challenge of providing a low 
pressure surface. 

Contact through the Ambulance Paramedic Lead Group which reports into the National Ambulance 
Service Medical Directors (NASMED) confirms that there is no similar innovation ongoing in any of 
the UK’s ambulance services.  Trusts who provided their guidance on pressure area management 
were similar to the education packages developed in the Trust (as shared above) but also included 
other protocols such as immediate ‘offload’ for patients at risk. 

A number of meetings with  Trust leads have informed the development of the device and it has 
been discussed with colleagues from various forums such as Health and Safety, Infection, Prevention 
and Control (IPC) and the Vehicle Working Group members who have identified how the device can 
be operated and stored on the Trust’s vehicles.  

Although there has been significant development there are still a number of steps to be finalised by 
the manufacturer and ourselves before we begin a pilot of the new mattress. 

I  hope  this  offers  you  reassurance  that  the  Trust  has  considerable  ongoing  work  to  address  the 
concerns you have shared within the Prevention of Future Deaths Report. If you have any further 
questions please do not hesitate to contact me, this can be done by writing to the address shown 
on this letter or by email to 

While writing I would like to offer my sincere condolences to Mrs Thomas’s family on their sad loss.  

Yours sincerely 

Chief Executive 

Enclosures: 

 
 
 
 
 
   
 
 
 •  Clinical Safety Plan 
•  Regional Escalation Action Plan 
•  Real-time Mitigation Report 
•  Reducing Patient Harm Action Plan 
•  Associated risks