Marjorie Michael

Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol 
Cabinet Secretary for Health and Social Care 

Ein cyf/Our ref 

Caroline Saunders,  
Senior Coroner  
Area of Gwent 
Civic Centre,  
Godfrey Road,  
Newport, 
NP20 4UR 

Dear Ms Saunders, 

18 September 2024  

Re: Regulation 28 Prevention of Future Deaths report – Marjorie Joyce Michael (deceased) 

Thank you for your correspondence of 26 July 2024 sent by email, in which you enclose a 
copy of a Regulation 28 Prevention of Future Deaths report (‘the report’) following the 
conclusion of the inquest into the death of Marjorie Joyce Michael. I would like to offer my 
sincere condolences to Ms Michael’s family on their sad loss. 

In the report you ask for an update on details of action taken or proposed by the Welsh 
Government to improve ambulance responsiveness and prevent future deaths in the Gwent 
area.  Whilst I have a role to set expectations in terms of a strategic direction for health and 
care services in Wales, and to hold the NHS to account, local health boards (LHBs) remain 
responsible for planning and delivering these services at a local level to meet the needs of 
the communities they serve.  

I will, therefore, firstly provide an update on action taken or proposed by Welsh Government 
followed by those actions reported to the Welsh Government being taken by the Aneurin 
Bevan University Health Board (ABUHB) and the Welsh Ambulance Services University 
NHS Trust (WAST). 

Welsh Government actions and support 

You will be aware the urgent and emergency care system in Wales, as with other parts of 
the UK, has been under often unrelenting pressure for a number of years as a consequence 
of a number of well-rehearsed factors. This includes 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. 

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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.   

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Overall management strategy to support improvement  

The NHS Wales Oversight and Escalation Framework sets out Welsh Government’s 
mechanism and approach for gaining assurance from NHS Wales organisations. The 
revised framework was published in January 2024 and sets out the Welsh Government's 
approach for gaining assurance from NHS Wales organisations; and the approach to 
escalation and intervention where there are matters of concern that need to be addressed. 

In line with the arrangements, the process for the escalation of concerns relating to NHS 
health bodies, including LHBs, is undertaken at a number of levels. Firstly, through the 
routine performance management mechanisms in place including regular integrated quality, 
planning and delivery (IQPD) meetings held with each NHS health body and chaired by 
either the Deputy Chief Executive of NHS Wales or the Welsh Government Director of 
Operations for NHS Wales. These meetings are used to raise and discuss concerns about 
the particular health body’s overall quality and safety of services and to undertake deep 
dives on specific topics.   

Joint Executive Team (JET) meetings are held twice a year between the senior teams of 
health bodies and the Welsh Government Health, Social Care and Early Years Group 
(HSCEYG). These are formal meetings to hold health bodies to account for performance, 
quality and safety, workforce and governance including an assessment of the organisation’s 
performance against national requirements, escalation and accountability conditions 

I remain concerned about the levels of ambulance patient handover delays reported across 
Wales, and LHBs must improve the timeliness of handover to release ambulance crews to 
respond to other patients in the community.  

We have been clear with LHBs that this is a priority for the Welsh Government in the 
national planning and performance frameworks, and through the Six Goals for Urgent and 
Emergency Care (‘six goals’) planning process. To further emphasise how we have 
prioritised improvement, we have also set LHBs in-year aspirations to reduce ambulance 
patient handovers over 1 hour by 30% by December 2024.  

We have put in place additional performance oversight arrangements to enhance scrutiny of 
LHBs’ delivery against these and other key ministerial targets through the new performance 
board arrangements. 
Years now holding monthly performance board meetings with LHB chief executives. 

, the Director General of Health, Social Care and Early 

Improving ambulance patient handover performance cannot be isolated to a single 
intervention, process or ‘silver bullet’ and requires a true whole system effort. This is 
because long ambulance patient handover delays are intrinsically linked to both difficulties 
experienced by community-based services to manage people safely in their home or local 
community, and challenges with supporting timely discharge of patients from hospitals to 
home.  

The former has an impact on available ambulance capacity as demand for a response and 
conveyance to hospital can increase at certain times of the day and during weekends in 
particular; and the latter has an impact on available bed capacity. A lack of available beds 
can occasionally result in patients waiting longer periods for admission which reduces 
available space in the emergency department, consequentially causing occasionally long 
delays for the transfer of patients from ambulances to the care of emergency department 
clinicians.  

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 The overarching Welsh Government strategy towards enabling better outcomes and 
experience for people who need to access urgent or emergency care services is set out in 
the Six Goals for Urgent and Emergency Care Policy Handbook. This strategy describes our 
expectations for LHBs and partners to place greater emphasis on assessing the needs of 
their local populations who are at greater risk of needing an ambulance response and 
admission to hospital, and coordinating their care through clear plans and wrap around 
support.  

The handbook sets out the intention to safely manage people who do not need to access 
the services of an acute hospital in their local communities, thus freeing up ambulance 
response and emergency department capacity for those who have an absolute clinical need 
for them.  

The handbook also describes expectations of LHBs to improve ambulance patient handover 
processes and to focus on timely flow of patients through the hospital system and out into 
the community.  

We established the six goals programme to enable LHBs to deliver on the objectives set out 
in our strategy, and have allocated an additional £50m in support over the past two years. 
The annual six goals allocation has increased to £27m in 2024/2025.  

Each LHB has developed a local ‘six goals’ programme plan for 2024/25 that incorporate 
actions to improve ambulance patient handover performance and patient flow, among other 
local priorities. This programme plan forms a key part of LHBs’ broader Integrated Medium-
Term Plans (IMTPs).  

This six goals programme is complemented by other national programmes including the 
Strategic Programme for Primary Care and the Regional Integration Fund (RIF) programme 
which, among other priorities, both focus on supporting safe avoidance of admission to 
hospital and enabling people to return home from hospital when ready.  

The RIF allocation of £145m per year is intended to create sustainable system change 
through the integration of health and social care services. Through the RIF’s Home from 
Hospital model of care activity, the Gwent Regional Partnership Board (RPB) is focusing 
their efforts on preventing hospital admission alongside expediting a swift discharge from 
hospital. This is helping people to return home from hospital in a timelier manner with the 
necessary support in place at discharge.  

I have clearly set out my expectations to ABUHB regarding the quality and timeliness of 
care to be delivered to people accessing care in the region, including those who are 
awaiting an ambulance response. This includes a focus on reducing ambulance patient 
handover waits and the time spent by patients in the emergency department, in addition to 
optimising quality and safety of care. 

Support to the Aneurin Bevan University Health Board 

We have provided an additional £6 million in six goals programme funding over the last two 
years to drive improvements in urgent and emergency care in Gwent, and the ABUHB will 
receive a further £2.7m this year. This funding has been used to develop new services and 
recruit key clinical leadership to oversee the ABUHB’s local programme plan. 

Further, national support has enabled the ABUHB to develop and deliver its local six goals 
programme plan, which includes new interventions to improve patient flow and reduce 
pressure on its emergency department.  

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 This includes development of urgent primary care centres at the Royal Gwent Hospital and 
Nevill Hall Hospital to better manage urgent care away from the Grange site, and SDEC 
services at the Grange University Hospital and Ysbyty Ystrad Fawr Hospital to help patients 
bypass the emergency department entirely. 

We have also allocated an extra £300,000 to ABUHB to deliver a new ‘e-triage’ tool, 
launched in June this year, at the Grange University Hospital which will enable rapid self-
triage to improve experience and identification of people who need early assessment.  

The Gwent RPB has also been allocated £27.2million in funding this year, and ABUHB will 
receive a share of Further Faster and Allied Health Professional funding.  All these funding 
streams are intended to either safely support fewer people to need to access services at the 
Grange University Hospital or improve flow across the system which will help to free 
capacity in the emergency department and reduce ambulance patient handover delays. 

Finally, following consideration of a business case submitted by ABUHB earlier this year, we 
have also provided £14m capital investment to support the expansion of the emergency 
department at the Grange University Hospital site. Improvements are expected to be 
completed by Spring 2025 and will double the current wait capacity (38) to provide 75 seats 
in total. There will also be an area dedicated to support the e-triage tool referenced above, 
with the existing waiting area repurposed to provide a rapid assessment area, both of which 
will help with timeliness of access – providing the right care and treatment more efficiently. 

Escalation of ABUHB to enhanced monitoring (Level 3) 

Performance particularly related to the Grange University Hospital emergency department is 
not where it should be. In line with our revised oversight and escalation framework, the LHB 
was, escalated to level 3 (enhanced monitoring) in January 2024.  

Welsh Government officials have agreed with the ABUHB an escalation framework that 
clearly identifies where improvements are expected to be seen for both performance and 
outcomes towards improvement in delivery of care at the Grange University Hospital 
emergency department.  

Whilst in escalation, ABUHB is held to account by Welsh Government through normal 
performance management arrangements such as IQPD and JET meetings. Further 
oversight is also in place through enhanced monitoring touchpoint meetings chaired by 
either the Deputy Chief Executive of NHS Wales or the Welsh Government Director of 
Operations for NHS Wales, as well as quarterly escalation meetings with LHB leads and 
chaired by the Chief Executive of NHS Wales. This includes a focus on progress made by 
LHBs on delivering the in-year aspiration to reduce ambulance patient handover delays 
over an hour in length by 30% by the end of December. 

Following the escalation of ABUHB to enhanced monitoring, and with specific regards to 
ambulance patient handover, we have observed gradual improvement. For example, each 
month of 2024 has seen a reduction in the number of handover delays over 1-hour in length 
at all ABUHB sites when compared to the corresponding month in 2023.  In July 2024, there 
was a 27% reduction when compared to July 2023.  However, there is more to do to 
continue this downwards trend and to support the timely release of patients and crews, and 
we will continue to monitor the position closely. 

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 Support to the Welsh Ambulance service 

The new NHS Joint Commissioning Committee (NHS JCC) was established on 1 April 2024 
and has responsibility for planning and securing emergency ambulance services for the 
people of Wales. It is for the committee to consider all relevant factors in determining the 
quantum of funding allocated to WAST for delivery of emergency ambulance services. I will 
hold the chair of the NHS JCC to account for effective commissioning of emergency 
ambulance services and achievement of the Ministerial priorities I have set of all 
organisations from 2024/2025 onwards.   

In terms of procuring ambulance vehicles, WAST submitted a Strategic Outline Programme 
(SOP) in 2016 that was endorsed by Welsh Cabinet Secretaries for its Vehicle Replacement 
Programme. The endorsement of the SOP allows WAST to submit Business Justification 
Cases (BJCs) setting out its vehicle replacement requirements on an annual basis. I will 
then make a decision on the BJC. Capital funding over the last three years is as follows:- 

•  2021-22 - £10.854m 

•  2022-23 - £12.230m 

•  2023-24 - £11.121m 

The SOP will be refreshed on a regular basis. It is important to recognise that the SOP 
covers the WAST fleet of vehicles and not only emergency ambulance vehicles.  

In addition to core funding, we provided £3m to the WAST in 2022/2023 to enable 
recruitment of 100 new staff. Since December 2021, there has been a 4.6% increase in 
WAST’s emergency medical services workforce in the ABUHB area.  

WAST also has access to national programme funding budgets including the six goals for 
programme’s innovation and delivery fund. We have targeted investment in 999 ambulance 
clinical triage resources and technology. This includes the use of video consultation 
technology which is helping to support around 4,500 (10-15%) patients without needing 
ambulance transport to an emergency department per month (in 2024/2025) to date.  

As described previously, plans to improve ambulance responsiveness in the ABUHB area 
are characterised by actions within the gift of WAST and ABUHB’s six goals programme 
plan; and joint plans with local authorities to improve patient flow.  

I note you have not requested an updated response to your report from WAST or ABUHB.   

You may wish to write to both organisations directly for further details on specific actions 
they are taking to improve ambulance responsiveness and prevent future deaths linked to 
delayed ambulance response, as they are responsible for delivery of services on the 
ground. I have provided a summary of the actions undertaken by ABUHB and WAST for 
information below, as reported to us by both organisations through ongoing monitoring 
arrangements undertaken by Welsh Government officials and the NHS Executive.    

Aneurin Bevan University Health Board actions 

Through delivery of its local six goals programme plan, ABUHB has interventions underway 
to reduce pressure on the emergency department at the Grange University Hospital and 
improve patient experience and outcomes. ABUHB provides quarterly updates on progress 
in delivering its six goals programme plan to the NHS Executive and specific elements of 
this plan to improve emergency care pathways at the Grange University Hospital are 

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 reported to the Welsh Government at monthly enhanced monitoring meetings. ABUHB has 
reported to us the following actions are in train: 

• 

Implementing a 24/7 urgent care service which includes minor injuries units and 
integrates the front door at the local general hospital sites – ensuring a seamless 
transition from in and out of hours services. 

•  Maximising the use of specialist advice and guidance lines with further integration of the 
frailty and ‘flow centre’ navigation system. The ‘flow centre’ is staffed by clinicians who 
are able to provide specialist remote advice to clinicians in the community who are at 
scene with patients helping to reduce unnecessary emergency department attendances 
and ambulance conveyances. 

•  A new hub comprised of clinical professionals is providing Community Resource Team 

(CRT) clinician capacity at the Flow Centre to support clinician to clinician conversations 
and triage of identified frail/older patients, including care home residents, to offer an 
appropriate alternative to acute admission.  

•  Early interventions to increase the number of elderly or frail patients supported at home 
and further development of SDEC frailty services to help patients bypass the emergency 
department entirely if they do need to attend hospital. 

•  Embedding of new falls pathway and development of fracture liaison services – reducing 

the future risk of falls and re-fracture. 

Welsh Ambulance Services University NHS Trust actions 

Our policy expectation, and the commissioning intent of the NHS JCC, is that WAST 
prioritises response to those in most need and aims to provide the right response, first time 
to optimise outcomes and experience.  

We expect WAST to work in partnership with LHBs to design and deliver consistent 
alternatives to ambulance despatch and conveyance to hospital. This is set out in our six 
goals policy handbook referenced earlier in this response. 

WAST has developed improvement plans for 2024/25 to help manage more people in the 
community, reduce conveyance to hospital and protect valuable resources for those most in 
need of an urgent response. Immediate actions include: 

•  Optimising use of its ‘Clinical Support Desk’, to manage up to 17% of patients 

remotely where clinically safe to do so and reduce the number of patients conveyed 
by ambulance to hospital; 

•  A targeted workforce plan to reduce sickness absence rates and increase available 

capacity;  

•  Additional volunteer capacity through WAST’s Connected Support Cymru initiative to 

aid decision making and support more patients to remain at home; 

•  A focus, with LHBs, on improving direct access into SDEC pathways, particularly for 
frail and elderly patients, to reduce conveyance to emergency departments and 
patient length of stay; and  

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 •  Full rollout of the Cymru High Acuity Response Units (CHARU) which provide 

specialised emergency responses to people with high acuity needs and is improving 
clinical outcomes for people who have suffered a cardiac arrest. Optimal utilisation of 
CHARU vehicles and practitioners will help preserve other urgent ambulance 
resources for other patients.   

Yours sincerely,  

Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol 
Cabinet Secretary for Health and Social Care 

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