Jeanette Sidlow Beech

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

Ein cyf/Our ref: A57494350 

Kate Robertson, Assistant Coroner  
North Wales (East and Central) 
Coroner’s Office 
County Hall 
Wynnstay Road 
Ruthin 
LL15 1YN 

24 July 2025 

Dear Ms Robertson, 

Re: Regulation 28 Prevention of Future Deaths report – Jeanette Sidlow Beech 
(deceased) 

Thank you for your correspondence of 29 May, enclosing a copy of a Regulation 28 
Prevention of Future Deaths report following the conclusion of the inquest into the death of 
Jeanette Sidlow Beech. Please pass on my condolences to Ms Beech’s family. 
I would like to set out the roles and responsibilities of the Welsh Government in relation to 
the health service in Wales, especially in support of timely ambulance responses. I also 
want to be clear that I expect the NHS to provide high-quality care to everyone and while 
the NHS is facing pressures, it is always disappointing when care falls below those 
standards. When mistakes and harm occur, I expect the NHS to learn from what happened 
and to apply that learning to prevent a further recurrence. Regulation 28 reports are an 
important part of that process. 
Governance: roles and responsibilities 

Welsh Ministers set the strategic context and expectations for health and care services in 
Wales and hold NHS organisations accountable for fulfilling their statutory duties. Welsh 
Ministers are not responsible for the delivery of health services.  

Health boards and NHS trusts are responsible for planning, commissioning and delivering 
services for the population of their local areas, in line with the national policy framework set 
by Welsh Ministers.  

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:  

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
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.   

 
 
 
 
               
 
 
 
 
 
 
 
 
 
 
  
 
 The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 
established the Welsh Ambulance Services University National Health Service Trust 
(WAST). Article 3 delegates the function of managing the ambulance service to WAST.   

WAST is therefore responsible for delivering emergency ambulance services in line with 
commissioning intentions set of it by the NHS Wales Joint Commissioning Committee 
(JCC). The JCC is a joint committee of health boards established to jointly exercise the 
functions of planning, securing and commissioning of emergency ambulance services.  
The Welsh Government’s policy expectation of health boards is that when a patient is 
conveyed to a hospital by ambulance, care must be handed over to the receiving hospital 
team as soon as possible, in order of clinical priority and within 15 minutes. Health boards 
are responsible for ensuring this happens reliably and that there is sufficient available 
capacity throughout the receiving hospital. This is set out in the Ambulance Patient 
Handover Guidance. 

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

I hold the chairs of all NHS organisations to account for oversight of the delivery of those 
expectations through regular meetings and Welsh Government officials maintain oversight 
of the delivery of services via Joint Executive Team meetings held biannually through 
regular integrated quality planning and delivery (IQPD) meetings where progress against 
key performance targets is scrutinised and assurance on the quality and safety of services 
is sought.  

Ambulance patient handover performance 

Ambulance patient handover delays at emergency departments in North Wales are too long 
and they are having an impact on patient outcomes; on staff morale in the ambulance 
service and the health board, and they are impacting on the ambulance service’s ability to 
respond to 999 calls in the community.  

As your report notes, addressing this requires co-ordinated action across the entire health 
and social care system.  
I have been very clear with Betsi Cadwaladr University Health Board – and with all NHS 
organisations in Wales – about the need to improve ambulance handovers at emergency 
departments. 
All health boards are required to implement the ambulance patient handover guidance – it is 
one of the five key priorities (‘enabling actions’) for urgent and emergency care within the 
NHS Planning Framework for 2025-26 and has been incorporated into the performance 
criteria for all health board chairs. 

To support health boards, my officials arranged a review of compliance with the ambulance 
patient handover guidance during the last quarter of 2024-25, which was completed by 
March 2025 by NHS Performance and Improvement. A report detailing the findings and key 
themes for health boards was shared on 18 June. A copy is attached at annex A.  

My officials have sought urgent assurance from each health board about how they will 
deliver specific actions against the eight aspects in this report to support compliance with 
the handover guidance and work towards delivery of no delays of more than 45 minutes by 
quarter three in 2025-26. Progress will be closely monitored by the Welsh Government and 
NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings. 
To further drive improvements, I announced on 30 June, a clinically-led National Handover-
45 Taskforce – the details are set out in this Written Statement.  

 The taskforce will use the NHS Performance and Improvement review as a foundation and 
will compile comprehensive evidence on effective strategies for improving ambulance 
patient handover. This will inform the development of an improvement programme and a 
readiness assessment.  
It will support all health boards and WAST to improve handover performance, working 
towards delivery of a standard ambulance patient handover within 15 minutes, with a 
backstop of 45 minutes. 

There have been signs of improvement in recent months. In June, across all emergency 
departments in Wales, there were 31% fewer ambulance hours lost as a result of 
ambulance patient handover delays and 24% fewer delays in excess of one hour compared 
to June 2024. In Betsi Cadwaladr University Health Board, there were 24% fewer 
ambulance hours lost, and 13% fewer patients delayed in excess of one hour when 
compared to June 2024. However, there remains a lot more to do, and I expect more 
progress and improvements to come. 

Planning for winter 2025-26 

As the winter period traditionally presents greater challenges for emergency care services, 
the process of learning lessons from last winter and developing plans for winter 2025-26 
started at the earliest possible stage, on 31 March. I chaired a Winter Summit meeting with 
NHS chief executives, directors of social services and the Association of Directors of Social 
Services (ADSS) Cymru.  

The expectations of health and social care partners, guidance and good practice have been 
issued to the NHS and local authorities and further operational winter resilience plans will be 
received from partners in the autumn. 

Escalation and Intervention 

Our approach to oversight, escalation and intervention is set out in the NHS Oversight, 
Assurance, Escalation and Intervention Framework. The framework sets out six escalation 
domains against which all health organisations are assessed. 

In line with the processes described within the document, Welsh Government officials 
undertake an assessment of each health organisation against each of the domains at least 
twice a year. These assessments draw in a variety of evidence and are used in conjunction 
with evidence and intelligence from statutory organisations by Welsh Government officials 
to inform the recommendations made to the Cabinet Secretary, on the escalation levels of 
NHS organisations in Wales. 

All health boards in Wales, are in escalation for urgent and emergency care, which includes 
ambulance handovers.  
Due to the serious concerns across a number of areas, including urgent and emergency 
care, Betsi Cadwaladr University Health Board was placed in special measures in February 
2023. 

The Welsh Government publishes regular reports setting out the progress made against the 
special measures criteria. It is evident from the recent reports that while some 
improvements are being noted across leadership and governance, concerns about 
operational grip and control across the organisation remain.  

 
 
 
 
 
 As part of the special measures intervention, the health board is receiving support from the 
Welsh Government, the Six Goals for Urgent and Emergency Care programme and NHS 
Performance and Improvement to make the necessary improvements to the quality and 
timeliness of its urgent and emergency care services and the experience of patients 
accessing its services.  

We have made an additional £2.7m available to the health board this year to support 
delivery of local improvement plans. This is part of £35.5m to support the health board and 
the North Wales Regional Partnership Board to safely manage more people in the 
community; to avoid ambulance transport and admission to hospital; and deliver integrated 
solutions with social care services to improve patient flow through hospitals. The impact 
made by the region is being closely monitored.  

Yours sincerely,  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex A: Assurance Review of Ambulance Patient Handover Process and 
Compliance with Guidance across NHS Wales 

NHS Executive Review of Ambulance handover guidance  (March 2025).pdf