Shirley Hughes

Cadeirydd 
Chair: 

Prif Weithredwr 
Chief Executive: 

Swyddfa'r Prif Weithredwr a’r Cadeirydd  

Chair and Chief Executive’s Office 

Our ref: 

4 December 2024 

Mr. John Gittins 

Senior Coroner for North Wales (East and Central)  

By email only to: 

Dear Mr Gittins 

Re: Mrs Shirley Ann Hughes 

I write in response to the Prevention of Future Deaths Report issued to this Trust on 28 October 
2025, following the inquest in relation to Mrs Shirley Hughes.  

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

“For  many  years,  myself  and  other  coroners  have  raised  concerns  regarding  so  called  “ambulance 
delays” and I recognise that the challenges faced by WAST around the availability of resources are the 
result of multifactorial issues, however on every occasion when evidence is presented at inquests, I am 
reminded that calls are prioritised using the Medical Priority Dispatch System (MPDS) by which a code 
is generated and that this is then matched to a response priority to provide an indication as to the 
most appropriate resource to respond.  

At the inquest of Mrs Hughes, I was advised that MPDS was introduced in 2015 and at that time it was 
envisaged that an amber 1 priority call would be responded to in 20 minutes, however it was clearly 
the case that the multifactorial issues which prevail today were not envisaged at that time and that as 
a consequence this raises questions as to whether the MPDS system remains fit for purposes. As a result 
of this evidence, I am concerned that lives are being put at risk.” 

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 would like to start by explaining that the MPDS system has been used by the Trust since the 1990’s 
and is the system by which the Trust prioritizes the calls it receives.  

To the Trust’s knowledge, MPDS and NHS Pathways are the only available products, worldwide. NHS 
Pathways is only used in England. In comparison to MPDS, NHS Pathways has a very small group of 
users, and the number of patients triaged using this tool versus MPDS is very small.  

In  the  absence  of  NHS  Pathways  or  MPDS,  it  would  require  significant  inhouse  development  to 
produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. 
During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, 
and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also 
deployed  Emergency  Communication  Nurse  System  (ECNS)  and  Call  Priority  Streaming  System 
(CPSS), both of which support our strategic direction. These are from the same provider as MPDS. 
There are a number of advantages presenting themselves, which is the potential synergies between 
MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 
and 111 contacts).  

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, 
, 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 Mrs Hughes’ 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 Mrs. Hughes’ 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 Mrs. Hughes’ 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 her 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