Peter Parker

Bwrdd Iechyd Prifysgol Bae Abertawe
Swansea Bay University Health Board

Un Porthfa Talbot | One Talbot Gateway
Parc Ynni, Baglan | Baglan Energy Park
Port Talbot SA12 7BR

Ffôn Phone: 

Dyddiad/Date: 11th December 2024 
Ein Cyf/Our Ref: 

Mr Aled Gruffydd 
HM Senior Coroner for Swansea and Neath Port Talbot 
The Guildhall 
Swansea 
SA1 4PE 

Dear Mr Gruffydd, 

Re: Inquest Hearing in respect of Mr Peter Parker (Ref: 13893868) 

Thank  you  for  providing  Swansea  Bay  University  Health  Board  with  an  opportunity  to 
address concerns raised at the conclusion of the Inquest of Mr Peter Parker, on 16th October 
2024.  

As you are aware the Health Board was not directly involved in clinical decision-making or      
care delivery immediately prior to Mr Parker’s death in September 2021 and as such were 
not a party to your Inquest hearing.  The Health Board’s last known contact with Mr Parker 
was  in  April  2021  in  relation  to  Type  II  Diabetes  Self-Management  Clinic,  which  was  a 
telephone contact.   

It  is  noted  that  in  evidence  submission  made  to  your  Inquest  by  the  Welsh  Ambulance 
Service NHS Trust (WAST), it was put forward that delay in releasing emergency response 
vehicles from the Emergency Department at Morriston Hospital was a factor in WAST being 
unable to respond to Mr Parker within an appropriate clinical timescale.  

The  Health  Board  accepts  that  routinely  there  are  substantive  delays  within  acute 
unscheduled care pathways, as a local, national and UK wide level.  These pathways can  
include  extended  waiting  times  for  emergency  vehicle  response  and  clinical  handover 
delays on arrival within acute secondary care.     

At  any  point  in  time  (24/7),  the  Health  Board  and  specifically  the  Hospital  Management 
Team at Morriston Hospital is aware of the number of open calls being managed by WAST, 
the clinical priority assigned to each of these calls, by WAST, and a very general comment 
on  clinical  presentation;  universally  referred  to  as  the  “stack”.    The  extent  of  information 
available, at this point is very limited and the Health Board has no role in determining clinical 
priority and resource allocation.    

Sadly, as described in your Inquest papers, WAST emergency vehicle attendance at the 
home address of Mr Parker was too late and he was declared deceased and therefore was 
not conveyed to Morriston Hospital, for emergency care.   

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at  oedi. 
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR  
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At this point I would like to take an opportunity to offer my heartfelt condolences to the family 
of Mr Parker.   

On occasions when such events have occurred, WAST have notified the Health Board of a 
potential  Serious  Incident  and afforded  the Health  Board time  to  reflect  on  the  case  and 
look  for  learning  opportunities,  this  process  has  been  in  place  since  circa  2019  and 
continues to date with outcomes shared at joint meetings between the Health Board and 
WAST. We have not been able to identify such a notification from WAST in relation to Mr. 
Parker. 

The agenda for the Health Board and WAST meetings is driven by exceptional cases, where 
severe/catastrophic  harm  has  been  identified.  The  meetings  are  held  monthly  and  are 
chaired by a Health Board Associate Nurse Director. (Outcomes from these meetings are 
available). 

In  lieu  of  a  case  review  not  being  undertaken  in  2021,  the  Health  Board  has  taken  the 
opportunity to apply its established review methodology to Mr. Parker’s case. 

The  following  key  aspects,  with  regards  to  the  Health  Board’s  response  to  unscheduled 
care pressures experienced across the 10th and 11th September 2021 are as follows: 

•  At  the  time  Mr.  Parker  contacted  WAST  (21:21,  10/09/2021),  there  were  3 
emergency  response  vehicles  outside  the  Emergency  Department  at  Morriston 
Hospital, awaiting clinical handover. 

•  During the period between the initial 999 call and the arrival of a WAST response 
vehicle  at  Mr.  Parker’s  address,  a  further  10  emergency  vehicles  arrived  at  the 
Emergency  Department  at  Morriston  Hospital  and  10  emergency  vehicles  were 
clinically  handed-over;  with  an  average  handover  time  of  192minutes  (range  784 
minutes to 13minutes). This includes the 3 vehicles outside Morriston Emergency 
Department at the time of the initial contact. 

•  This case occurred when enhanced infection prevention protocols related to COVID-
19 were still in place, within the Emergency Department and across the hospital site, 
which could have impacted on the speed of clinical handover for some patients in 
order that appropriate risk assessment was undertaken to ensure patient and staff 
safety.  A  high-level  review  of  the  cases  arriving  by  ambulance  on  10th  and  11th 
September 2021,  supports this,  with a number patients presenting  with  breathing 
problems. 

• 

It is apparent from evidence provided by WAST, that there was a significant increase 
in WAST demand during the period Mr. Parker was awaiting a response, with the 
number of Amber1 calls increasing from 11 (at 22:28 with a longest waiting time of 
7hours 24minutes) to 21 (at 02:19 with a longest waiting time of 9hours 40minutes). 

It is noted that the Serious Incident Review undertaken by WAST concluded that due to the 
number of Amber1 calls polling ahead of Mr Parker, they could not have responded to his 
call any sooner.  

A multi-faceted risk to delivery of unscheduled care is recognised on the Health Board’s 
Risk Register and is scored at 25. 

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at  oedi. 
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR  
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

 
 
 
 
 
 
 
 
 
 
 
 Since  Mr Parker’s  death  the  All-Wales  National Immediate  Release  Protocol (July 2022) 
has been introduced (a copy is attached for reference). The objective of this protocol is to 
provide  an  escalation  process,  across  NHS  Wales,  that  ensures  WAST  resources  are 
released  when  required  to  mitigate,  in  real-time,  serious  cases  of  potential  harm  from 
occurring because of an avoidable delayed response in the community.  

The protocol is designed to work alongside, and not replace, organisational management/ 
clinical safety plans. It is designed to complement joint working to reduce harm and improve 
patient safety.  

The protocol sets out a clear process for request/escalation and requires Health Board’s to 
investigate all occasions when an immediate release is declined.  

In summary the steps (S.5) are set out below: - 

Step 1 – WAST will contact ED staff via the “red phone” and direct an immediate release 
of an ambulance delayed outside the ED when no other appropriate resource is available 
to respond to a Red or Amber1 patient and/or when the resource has an extended travel 
time  and  nearer  appropriate  resources  could  attend  that  patient.  The  direction  made  by 
WAST will share the incident priority, patient age and chief complaint, identify the number 
of  resources  that  are  required  to  be  released  and  the  callsigns  of  the  resources  to  be 
released (those that are immediately able to respond to the incident).  

Step 2 – Health Board colleagues on receipt of an immediate release direction will ensure 
compliance and facilitate the release of the resources identified without delay.  

Step 3 – Should an immediate release direction be declined by the ED staff, WAST will act 
in  accordance  with  the  WAST  Resource  Deployment  SOP  and  record  and  escalate  the 
refusal  to  the  Operational  Delivery  Unit.  If  a  Health  Board  does  decline  an  immediate 
release  direction,  they  will  be  required  to  provide  the  reasons  for  this  and  the  name  or 
identifying detail (e.g., employee number) of the declining staff member. 

The reason for handover delays is solely related to a lack of capacity to bring the conveyed 
patient into the hospital; both in terms of safe physical space including access to essential 
clinical support and staffing to take care of the patient. All patient’s waiting on the back of 
ambulances will have been clinically assessed and all opportunities explored as to how best 
to deliver a safe, timely, clinical management plan. The Emergency Department at Morriston 
Hospital routinely functions with additional patients across its template including within the 
acute  resuscitation  area,  with  “Major”  patients  overflowing  into  the  “Minors”  area  and 
“Minors” patients sitting in the “Waiting Room”. 

It is important to note that patients can and do self-present at the Emergency Department 
with significant clinical presentations that require immediate clinical intervention and this is 
a feature when WAST waiting times for an emergency vehicle are long. This represents a 
secondary route for very unwell patients to present at hospital that needs to be considered 
in assessing safety within the Emergency Department. These patients can be more clinically 
urgent than patients arriving by emergency response vehicle. 

I  can  confirm  that  all  Red  release  requests  are  actioned  by  the  Health  Board.  Amber1 
release requests are managed on a case-by-case basis and the Health Board may have to 
decline  requests  when  there  is  a  significant/severe  clinical  safety  risk  to  the  Emergency 

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at  oedi. 
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR  
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

 
 
 
 
 
 
 
 
 
 Department, in accepting additional patients into the Department. This risk is assessed at 
a point in time, by the senior clinical staff in-charge of the Emergency Department (medical 
& nursing) and would be consistent with the nationally reported emergency care status or 
SAPhTE score (Staffing, Acuity, Physical Capacity, Transfer, Environment). The decision 
is documented and notified to the Hospital Site Management Team who record it as part of 
the situation reporting throughout any 24hour period.   

The Health Board actively monitors ambulance handover performance against the following 
two performance measures, on a daily basis: 

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

15minutes) 

Diagram1: Ambulance Handover Performance covering the period 1st November 2022 
to 30th November 2024: 

(Source: Health Board Performance Scorecard – weekly update 03/12/2024) 

The above graphical representation demonstrates the number of delayed WAST handovers 
(>1hour) has reduced by 15% (744 in November 2022, to 632 in November 2024) and the 
number of lost hours (>15mins) as a result of handover delays has significantly reduced by 
32% (4456 hours in November 2022 to 3028 hours in November 2024).  

The Health Board has commenced a programme of targeted intervention in conjunction with 
the  National  Strategy  for  Right  Care,  Right  Place,  First  Time:  Six  Goals  for  Urgent  & 
Emergency Care, supported by Welsh Government, to address risks associated with urgent 
and  emergency  patient  pathways,  including  the  ability  to  release  emergency  response 
vehicles, following arrival at Morriston Hospital. The aim of this programme of work is to 
critically review and redesign across community access, service delivery, staffing models 
and infrastructure in order to reduce risk of patient harm and service failure.  

Right Care, Right Place, First Time: Six Goals for Urgent & Emergency Care 
The above strategy focuses on strengthening signposting to clinically safe alternatives to 
admission,  rapid  emergency  care  response,  good  discharge  practice  and  preventing 
readmission.  

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at  oedi. 
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR  
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 

                                                                                                                                                                                                                                                                    
 
 
 
 
 
 
 
 I have attached a copy of the Policy Document, for your information.  

In  support  of  delivery  of  this  programme  of  work  the  Health  Board  has  an  Urgent  and 
Emergency Care Project in place, which is led by the Morriston Service Group. 

With reference to Goal 2&3: Signposting people with urgent care needs to the right place, 
at the right time and providing clinically safe alternatives to admission to hospital 

It  is  anticipated  that  in  ensuring  that  there  are  robust  alternatives  to  presenting  at  an 
Emergency  Department,  there  will  be  a  reduction  in  demand.  This  in  turn  will  enable 
Emergency Departments to better manage patient flow and capacity.   

In developing this model, a Same Day Emergency Care (SDEC) service is available on the 
Morriston  Hospital  site.  Providing  an  alternative  to  presentation  at  the  Emergency 
Department.  This  service  can  sign-post  and  facilitate  urgent  review  into  specialist  “hot” 
clinics and represents a tangible link between primary and secondary care services. 

In addition, the Health Board have developed an Acute Medical Unit and recently opened 
an Older Person’s Assessment and Short Stay Unit (June 2024) on the Morriston Hospital 
site, which again provides alternative pathways for patient’s presenting to the Emergency 
Department and funnels into appropriate care delivery settings, including being supported 
at home by services such as the “Virtual” Ward and Acute Care Team. 

With reference to Goal 4: Rapid response to physical or mental health crisis.  

This goal focuses specifically on safe alternatives to ambulance conveyance into secondary 
care, thus enabling a more responsive service to patients who are in danger of losing their 
life or require access to time-sensitive treatment; such as that for Stroke or life-threatening 
injury.  

There is an inherent expectation that the number of people waiting over 60minutes between 
arriving by ambulance and being handed over to a clinician, reduces year on year (as per 
Diagram1).  

I would like to offer my sincere condolences to Mr Parker’s family on behalf of the Health 
Board. Whilst it is fully appreciated that these developments will not change the outcome 
for Mr. Parker and his family, I hope that you are assured that the Health Board has a clear 
focus  on  improvement  in  access  times  for  unscheduled  care  with  an  aim  of  preventing 
events, such as those identified in Mr. Parker’s case, from occurring today and in the future.   

Yours sincerely, 

Chief Executive  

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at  oedi. 
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. 

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR  
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe 

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

Cadeirydd 
Chair: 

Prif Weithredwr 
Chief Executive: 

Swyddfa'r Prif Weithredwr a’r Cadeirydd  

Chair and Chief Executive’s Office 

Our ref: 

Your ref: 

4 December 2024 

Private & Confidential 

Aled Gruffydd  

Assistant Coroner Swansea Neath & Port Talbot 

By email only to: 

Dear Mr Gruffydd 

Re: Mr Peter Parker 

I write in response to the Prevention of Future Deaths Report issued to this Trust on 22 October 
2025, following the inquest in relation to Mr Peter Parker.  

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

“There was a significant delay in getting an ambulance to Peter which resulted in him dying from his 
injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however 
the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls 
it was envisaged that when the system was introduced such calls would be responded to in 20 minutes” 

Additionally, you have stated: 

“The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that 
an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a 
person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not 

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 

 
 
 
 
 
 
 
 
 
 
 
 feasible  for  Peter  to  transport  himself  to  hospital,  and  Peter  had  not  contacted  his  family  for  their 
assistance.” 

I would like to start by explaining that the Medical Prioritisation and Dispatch System (MPDS) is used 
by the Trust to prioritise the calls it receives and was adopted during the 1990’s. Your reference to 
2015, we believe refers to the trial of a new Clinical Response Model (CRM) which commenced in 
October 2015. The CRM guides the way in which the Trust utilises its resources. An initial trial was 
undertaken  for  12  months  and  extended  by  a  further  6  months.  In  February  2017,  the  CRM  was 
approved by Welsh Government and has remained in place since that time.  

During the trial of the Trust did have in place an internal only target to attend Amber 1 calls in 20 
minutes. For clarity this was purely an internal, non-official target, which ceased when the CRM was 
fully adopted in 2017. Since 15 October 2015, the Trust has had only one official time based target, 
and that is in relation to an 8 minute response to 65% of ‘Red’ cases. 

You may now be aware that on 26 November 2024, the Cabinet Secretary for Health and Social Care, 
Jeremy Miles, announced the establishment of a task and finish group to review our current “red” 
target  and  associated  metrics.  This  comes  after  the  Senedd’s  Health  and  Social  Care  Committee 
published  a  series  of  recommendations  in  August  following  its  general  scrutiny  of  the  Welsh 
Ambulance Services University NHS Trust in May 2024. The scrutiny report has been included as an 
appendix to this letter (Appendix 1). The emergency ambulance response measures task and finish 
group  will  comprise  of  senior  civil  servants  and  policy  leads,  representatives  of  the  Joint 
Commissioning Committee (JCC), clinicians and members of our leadership team. This group will 
work at pace and is due to report to the Cabinet Secretary early next year with a view to updating 
Committee, and Senedd members, by the end of February 2025. 

The  Trust  does  not  propose  to  take  any  additional,  or new,  actions  specifically  in  relation  to  this 
Preventing  Future  Deaths  report  because  of  existing  plans  already  being  enacted.  Whilst  we 
recognise that this may appear insensitive given the loss Mr Parker’s family have experienced and in 
light of the risks you raise with us, we hope to provide assurance that the Trust already recognised 
the risks and pressures within Urgent and Emergency care pathways and 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 its commissioners through it commissioning body, the JCC, 
Welsh  Government,  the  wider  NHS  and  Local  Government  to  ensure  appropriate  clinical  risk 
management across the urgent and emergency care pathway to release resources with the Trust.   

In addition to the Governmental task and finish group referenced above, and aligned to our 2024-
27 IMTP, the Trust has commenced work to evolve its Clinical Services Model. We have provided an 
overview of our current position and planned incremental changes under the headings below. 

Current Situation 

▪  We fully understand and acknowledge the long standing and entrenched problems facing 

health and social care services.  

▪  The challenges facing the system are complex, and not easily solved by a single organisation 

unilaterally.  

 
 ▪  This is no consolation for families who have been caught up in the challenges of the current 

▪ 

system.  
It is our view that the traditional ambulance model of care needs updating to reflect both 
increasing clinical skills of  staff and increasing opportunities presented by technology. We 
need to think differently.   

▪  As a result, we recognise that there is more we need to do ourselves to improve patient care 

and experience for patients calling 999.  

▪  We are looking to potentially do things differently in the future and are working closely with 
commissioners on the art of the possible in terms of ‘evolving’ our clinical services model.  

What are we looking to achieve?   

▪  Protect our ambulance resources for patients most in need of an ambulance response 
▪  We only want to convey patients to hospital whose needs cannot be met by the Trust or in 

another part of the system.  

▪  Enhance our ability to resolve more care through the Trust led interventions without needing 

an emergency ambulance response. Including:  

o  Enhancing our ability to manage more patients’ needs remotely following a remote 

clinical assessment.  

o  Patients’ needs are met in their own home following a face to face clinical assessment 
through  an  enhanced  community  response  services   (e.g.,  Advanced  Paramedic 
Practitioners, Falls Response, Mental Health Vehicle).  
Improve  access  to  signpost  /  refer  patients  whose  needs  are  best  met  by  another 
service. 

o 

Core foundations of the model 

▪  The core foundations of the model are set out below: 

o  Clinically  led  –  there  will  be  increased  clinical  input,  earlier  in  the  call  cycle  and 
throughout the patient journey. Clinicians will be actively involved in decision-making 
on the right pathway for each patient as part of a care planning process.  

o  Connectivity  –  systems,  processes  and  people  across  the  Trust  will  be  increasingly 
connected so that patients get the right care in the right place, irrespective of their 
point of access (e.g., Digital access, NHS 111, 999 or the Ambulance Care service for 
non-emergency patient transport). 

o  Care Planning: We will adopt a personalised care planning approach for all patients, 
providing robust clinical oversight of the patient throughout their episode of care until 
their needs are resolved and case closed with the ambulance service.  

o  Choice: A greater range of response options will be created for those patients who 
need a face-to-face assessment, designed to enable more patients to be treated safely 
at home and to avoid conveyance to an Emergency Department.  

o  Collaboration:  Increased  effort  will  be  put  into  working  with  commissioners  and 
system partners at national and local level to identify and develop appropriate care 

 
 pathways for the Trust clinicians to safely and appropriately refer patients to meet their 
care needs. 

What are our current priorities?   

▪  We are in close collaboration with Welsh Government, our commissioners and health boards 
to focus on opportunities for improvement, including improving access to local pathways of 
care to provide more options to safely avoid patients being conveyed to hospital.  

▪  As part of our plans for winter we are embedding new clinical roles in our control rooms to 
proactively triage 999 calls earlier in the call cycle. By using clinical expertise, it enables more 
effective clinical decisions regarding the best care to meet the patient’s needs.  

What will be the impact?  

▪  We will be monitoring the impact of these developments and working with commissioners 
and partners to work through opportunities for further development and collaboration.  

When will we see changes?  

▪  Our aim in the short term is to make the service ‘safer’ over this winter.  
▪ 

Implementation of an evolved model of care (pending commissioner endorsement) will be 
delivered in a phased approach, and the programme is likely to run for period of circa 2/3 
years.     

▪  We expect to see incremental improvement as different interventions are implemented and 

embedded throughout the programme timescales.  

▪  We recognise that no single intervention can fix the problem.   
▪  The level of improvement is dependent upon how well the wider system is functioning.   

Ongoing Engagement  

▪  We continue to work with partners across the system, commissioners and Welsh Government 

on collective support and action so that we can make further improvement.  

▪  We will be undertaking more targeted engagement with key stakeholders, including coronial 

services, to support our emerging plans in the near future.  

We hope that this information supports our position that we are doing everything within our sphere 
of  control  and  influence  to  deliver  more  timely,  safer  care  however  we  are  acutely  aware  of  the 
limitations of our actions within the wider health and care landscape of extreme pressures across 
Urgent and Emergency Care systems. The number of hours' worth of Trust emergency ambulance 
production lost per month due to long waits at emergency departments is consistently reaching the 
25,000 to 30,000 hours mark. This equates to approximately 20 per cent to 25 per cent of our entire 
fleet capacity every month as a result of the pressure right across the urgent and emergency care 
system. This issue remains the highest influencing factor on our ability to provide timely responses, 
far above and beyond the incremental improvement measures being taken internally by the Trust. 
To  this  end,  Welsh  Government  released  a  revised  Welsh  Health  Circular  (WHC-2024-041)  on 
‘Ambulance patient handover guidance’ shortly following the conclusion of Mr Parker’s inquest. This 
document replaces the existing 2016 WHC on the same subject and reinforces the expectation that 

 “robust  arrangements  are  in  place  to  ensure  rapid  handover,  within  15  minutes  of  arrival”. 
(Appendices 3 and 4) 

While  the  Trust  fully  supports  the  need  to  issue  a  report  under  paragraph  7,  Schedule  5,  of  the 
Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners  (Investigations) 
Regulations 2013, we do not believe that we are the primary authority with the “power to take such 
action”. Therefore, I respectfully request your consideration as to any further actions you feel the 
Trust  could  take,  over  and  above  those  that  we  have  already  shared  with  you.  Equally,  I  would 
genuinely welcome any suggestion you may have regarding actions we might take or seek to take 
with our partners.  

We  continue  to  work  tirelessly  at  internal  mechanisms  to  reconfigure  and  improve  resource 
allocation,  regularly  reporting  to  our  Trust  Board  on  the  steps  taken  to  mitigate  patient  harm. 
However, we recognise that we are not an organisation with a full solution in the broader context. I 
am therefore extending an 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 proactively prevent harm and future deaths.  

I  would  like  to  again  offer  my  sincere  condolences  to  Mr.  Parker’s  family  on  their  sad  loss.  Any 
reference to the systemic nature of the root causes for delays are in no way intended to be dismissive 
of the unacceptable and tragic loss of life and the grief his family are experiencing.  

If you wish to take up the offer of a meeting with myself or a member of my Executive team, please 
contact 
, Legal Services Manager, who will be happy to arrange this. Her contact 
email is 

 and her telephone number is: 

. 

Yours sincerely 

Chief Executive 

Appendices 

1.  WAST Senedd General Scrutiny report Aug 2024 
2.  WHC-2024-041 - Letter - Ambulance patient handover guidance 
3.  WHC-2024-041 - Ambulance patient handover guidance

Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol/ 
Prif Weithredwr GIG Cymru 
Grŵp Iechyd a Gwasanaethau Cymdeithasol 

Director General Health and Social Services/ 
NHS Wales Chief Executive 
Health and Social Services Group 

Mr Aled Gruffydd, Assistant Coroner  
Swansea Neath & Port Talbot 
Civic Centre  
Oystermouth Road  
Swansea 
SA1 3SN 

Our Ref: 

Your Ref: C

13 December 2024 

Dear Mr Gruffydd 

INQUEST INTO THE DEATH OF PETER PARKER  

Thank you for your correspondence dated 22 October received in my office on 7th 
November, 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 Peter Parker. I 
should like to offer my sincere condolences to Mr Parker’s family on their sad loss. 

In the report you ask for details of action taken or proposed by the Welsh Government to 
improve timeliness of ambulance response to aid prevention of future deaths.  

I note you have also written to the Chief Executive of Swansea Bay University Health Board 
(which is responsible for planning and delivering services based on an assessment of local 
population need), and the Chief Executive of the Welsh Ambulance Services University 
NHS Trust (which is responsible for delivering emergency ambulance services in line with 
commissioning intentions set of it by the NHS Wales Joint Commissioning Committee). The 
independent responses of the health board and the trust should detail the respective actions 
taken by each organisation to address your concerns. 

A summary of urgent and emergency care system pressures 

You are likely to be aware that urgent and emergency care services in Wales, as with other 
parts of the United Kingdom, have been under often unrelenting pressure for a number of 

Parc Cathays ● Cathays Park 
Caerdydd ● Cardiff 
CF10 3NQ  

Gwefan ● website: www.wales.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 years. In summary, this is as a consequence of challenges presented by changing 
demographics, increasing prevalence of people with multiple chronic conditions and 
difficulties in supporting the timely discharge of patients to local communities caused by a 
range of factors. These factors include high hospital bed occupancy, delayed discharges 
caused by inefficient hospital processes and staffing shortages in key parts of the health 
and social care system.  

Delayed patient discharge is a key contributing factor to long ambulance patient handover 
delays. This is because poor patient flow causes bed occupancy levels to increase, 
resulting in patients waiting lengthy periods for admission to hospital from emergency 
departments which, consequently, limits available space for patients arriving by ambulance 
to be transferred to the emergency department itself.  

This can result in long ambulance patient handover delays, impacting negatively on patient 
experience and crucially limiting available ambulance capacity to respond to other patients 
in the community.  

Expectations and monitoring of urgent and emergency care improvements 

These issues are all connected and require whole system strategic change and leadership 
to overcome them. The overarching Welsh Government strategy towards improvement is 
set out in A Healthier Wales. Aligned to this strategy, to enable better outcomes and 
experience for people who need to access urgent or emergency care services, the Welsh 
Government published the Six Goals for Urgent and Emergency Care Policy Handbook in 
February 2022.  

This handbook describes our expectations for health boards and partners to support people 
in their local communities who are at greater risk of needing an ambulance response, 
transport to an emergency department and admission to hospital, and coordinating their 
care through clear care plans and support from local community teams.  

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 Welsh Government communicates its expectations of health boards and NHS Trusts 
through an annual NHS planning framework and organisations are expected to produce 
integrated medium-term plans annually that respond to the priorities set in the NHS planning 
framework.  

For the past two iterations of the framework, the Welsh Government has been explicitly 
clear of our expectation that health boards prioritise plans to improve timeliness of 
ambulance patient handover to free up ambulance clinicians to respond to patients in the 
community. Given the relationship between both timely patient discharge and ambulance 
patient handover, the Welsh Government has set a priority for improvement in patient flow 
and the reduction of delayed discharges (pathways of care delays). To build on this, the 
Welsh Government has also set health boards in-year aspirations in 2024/2025 to reduce 
ambulance patient handovers over 1 hour by 30% by December 2024.  

The Welsh Government has put in place additional performance oversight arrangements to 
enhance scrutiny of health boards’ delivery against these and other key ministerial targets 

2 

 
 
 
 
 
 
 
 
 
 
 through the new performance board arrangements. I am now holding monthly performance 
board meetings with health board chief executives. 

Support via the national Six Goals for Urgent and Emergency Care programme 

To enable health boards to deliver on our expectations, the Welsh Government established 
a national six goals for urgent and emergency care programme which is supported by 
£27million in funding for 2024/25. The Welsh Government also directed health boards to 
establish local six goals programmes to drive improvement of urgent and emergency care 
services and each health board has a local programme plan intended to deliver against 
ministerial priorities.  

Successful delivery of these plans should support improvements across a range of 
measures, including the reduction of ambulance patient handover delays contributing to 
improved ambulance responsiveness. Progress in delivering these priorities is monitored 
through bi-monthly Integrated Quality, Planning and Delivery meetings between Welsh 
Government officials, representatives of the NHS Executive and health boards.  

This six goals funding is part of a wider package of more than £180million in additional 
Welsh Government funding this year to support health boards and regional partnership 
boards to: 

•  safely manage more people in the community;  
•  avoid ambulance transport and admission to hospital; and  
•  deliver integrated solutions with social care services to improve patient flow through 

hospitals.  

Other initiatives to support improvements in ambulance patient handover and patient 
flow 

More recently, the Welsh Government has developed new ambulance patient handover 
guidance – published on 29 October 2024 which sets out expectations of the NHS Wales 
Joint Commissioning Committee, ambulance clinicians and health boards to support 
improved ambulance patient handover. The NHS Executive will undertake audits of 
organisations’ compliance with the guidance over the remainder of 2024/2025, and we have 
been clear that health boards must also undertake their own audits of compliance.  

Additionally, the Welsh Government commissioned the development of a community based 
falls response framework which was published by the NHS Executive on 30 October 2024 
and a national task group established to enable health boards to deliver. The intention is to 
better support people who have fallen but are not seriously ill or injured, to safely avoid the 
need for an ambulance response or transport to emergency departments, thus reducing 
ambulance patient handover delays and improving experience and outcomes.  

The Welsh Government has also recently launched a 50-day integrated care winter 
challenge (‘the challenge’) based on learning from other parts of the UK. The Welsh 
Government identified ten high-impact and best practice actions for health boards, regional 
partnership boards and local authorities to deliver between 11 November and 31 December 
2024..  

The challenge is intended to accelerate and standardise delivery of safe alternatives to 
admission to hospital and support timely discharge home and is enabled by an additional 

3 

 
 
 
 
 
 
 
 
 
 
 
 £19m announced by the Cabinet Secretary for Health and Social Care on 3 December 
2024.  

The Welsh Government are monitoring progress very closely and will review lessons 
learned following completion of the initial 50 days on 31 December 2024 to support 
sustained implementation of the best practice actions in 2025 and onwards. The Welsh 
Government also continues to engage regularly with other UK nations to learn lessons 
about solutions to the ambulance patient handover issue and will be seeking to transfer 
learning to improve performance in Wales in 2025. 

Wider NHS escalation and intervention arrangements 

Finally, although some progress has been made by the Swansea Bay University Health 
Board in some areas, concerns about delivery of urgent and emergency care and other 
areas led to the Welsh Government escalating the organisation to level 4 (targeted 
intervention) status in January 2024 for performance and outcomes. This means that the 
Welsh Government are now scrutinising the health board’s performance extremely closely. 
In response, the health board is prioritising a range of actions to support better patient 
outcomes and experiences in the months ahead. The health board remains at level 4 as the 
necessary improvements have not yet been seen. 

As part of this escalation, additional support has been given to the health board from the 
NHS Executive to support improvements in urgent and emergency care. These actions are 
being monitored and reviewed in monthly oversight meetings. 

Yours sincerely 

4