Angela Darlow

Jeremy Miles AS/MS 
Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol  
Cabinet Secretary for Health and Social Care 

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

24 March 2026  

Dear Ms Robertson 

Re: Regulation 28 Prevention of Future Deaths report – Angela Frances Darlow (deceased) 

Thank  you  for  your  letter  and  the  Regulation  28  Prevention  of  Future  Deaths  report  of  5 
February  following  the  conclusion  of  the  inquest  into  the  death  of Angela  Frances  Darlow. 
Please pass on my condolences to Ms Darlow’s family. 

I take incidents of delays to NHS care and incidents where care does not meet our high 
expectations of the NHS extremely seriously. A 23-hour wait for an ambulance following a 
stroke is clearly not acceptable and is indicative of serious issues in the wider health and 
care system. 

Your report rightly outlines concerns about the levels of demand faced by the Welsh 
Ambulance Services University NHS Trust (WAST) when Ms Darlow experienced a stroke 
as well as issues related to ambulance patient handover delays, patient flow, and social 
care provision for people in North Wales who are served by Betsi Cadwaladr University 
Health Board and the six local authorities responsible for health and social care services.  

Ms Darlow was conveyed to the Countess of Chester Hospital, which provides NHS 
services to people in Wales who live close to the boarder with England. Betsi Cadwaladr 
University Health Board commissions the service.  

Thank you for providing this Regulation 28 report – this is an opportunity for the health 
board, WAST, their partners and the Welsh Government to learn from what went wrong in 
Ms Darlow’s case and to put in place changes to address these failings.    

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

C

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.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Welsh Ministers set the strategic direction for health and care services and hold NHS 
organisations to account. Welsh Ministers are not responsible for the delivery of health or 
social care services. Health boards and NHS trusts are responsible for planning, 
commissioning and delivering services for the population of their respective areas within the 
national policy framework set by Welsh Ministers.  

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

Managing 999 ambulance demand 

In July 2025, a new emergency ambulance performance framework was introduced in 
Wales, supporting a move away from time-based targets towards a more clinically driven, 
outcome-focused approach, with an emphasis on responding quickly to people with 
time-sensitive conditions.  

Two new categories of call were initially introduced in July – a new purple category for 
people suffering a suspected cardiac and respiratory arrest and the red category for people 
at high risk of cardiac and respiratory arrest, including where this is a result of injury or 
illness. 

As part of the framework, all 999 calls to WAST, which are not classified as either purple or 
red, go through rapid clinical screening to ensure everyone receives a more tailored 
approach. This means the ambulance service takes account of their symptoms and where 
the incident occurred to determine what sort of response they receive. Every person 
receives a tailored response but not everyone will need an ambulance – they may receive a 
different clinical response, which is appropriate to their needs. An additional 28 clinical 
advisers – new posts – were recruited to support this new process to ensure people get the 
right response the first time. 

The next phase of the framework was introduced in December, following a clinical review of 
the amber and green categories of call. A new orange – time-sensitive response category 
was introduced. This was designed to ensure people with conditions such as suspected 
stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact 
centres to receive a faster, more appropriate ambulance response, and rapid transport to 
specialist care.  

The new framework also increases opportunities to better understand patient outcomes and 
experience by broadening measurement beyond initial response times to include more 
clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer 
insight into the timeliness and quality of care delivered to patients with serious and 
time-sensitive conditions, including stroke, to drive quality improvement.  

The changes are being tested for 12 months and will be thoroughly evaluated. 

Improving ambulance patient handover performance  

As set out in my response to you in July 2025 to a previous Regulation 28 report, all health 
boards are expected to deliver the Ambulance Patient Handover Guidance. This was updated 
in January 2026 and issued to health boards for immediate delivery. 

 
 
 
 
 
 This reinforces that ambulance patient handover is a whole system responsibility, requiring 
co-ordinated  action  across  all  parts  of  the  NHS  and  aligned  to  existing  escalation 
arrangements.  It  also  expects  a  more  consistent  approach  to  monitoring,  assurance,  and 
accountability,  enabling  system  leaders  to  identify  and  address  the  underlying  causes  of 
handover delays rather than managing the symptoms alone. 

Delivery of the guidance is one of five priorities  – called enabling actions – for urgent and 
emergency care in the NHS Planning Framework 2025-26 and will be maintained as a priority 
for  2026-27.  It  is  also  a  feature  of  every  health  board  chair’s  objectives  as  a  marker  of 
performance. 

I  set  up  a  clinically-led  National  Handover-45  Taskforce  last  year  to  support  delivery  of  a 
recommendation  made  by  the  Ministerial  Advisory  Group  on  NHS  Performance  and 
Productivity to eliminate ambulance patient handover delays of more than 45 minutes. The 
taskforce has brought together senior clinical, operational and system leaders from across 
NHS  Wales  and  has  overseen  focused  improvement  activity,  shared  good  practice,  and 
provided national clinical leadership on safe and timely handover.  

Its  work  has  helped  to  strengthen  understanding  about  why  handover  delays  happen, 
reinforced the importance of whole-system flow, and supported measurable improvements in 
handover performance across a majority of hospital sites in Wales.  

In  February  2026,  across  all  emergency  departments  in  Wales  there  were  21%  fewer 
ambulance hours lost as a result of ambulance patient handover delays and 19% fewer delays 
in excess of one hour compared to February 2025.  

However, despite some gradual improvement in the Betsi Cadwaladr University Health Board 
area over recent months, the pace of improvement is not where it needs to be and the three 
district  general hospitals have  the  worst  performance  in Wales.  I am  concerned  about  the 
ongoing level of ambulance patient handover delays in North Wales and the impact this has 
on  ambulance  availability  in  the  community.  I  have  been  very  clear  with  the  health  board 
about my expectation for sustained improvement in this area and in improving patient flow 
through the hospitals and the wider health and care system in North Wales. 

Patient flow in acute hospitals  

As highlighted in your report, some of the issues the NHS is experiencing at the moment are 
because people are not being discharged home quickly when they ready to leave hospital. 

The NHS and local authorities took part in two winter sprint fortnights in December 2025 
and January-February 2026 – these were periods when all organisations focused on a set 
of actions to improve flow through the health and care system, with the intention of 
embedding the learning into business as usual working. During the sprint periods, more 
people were discharged earlier in the day, and there was better use of discharge transport 
capacity and fewer ambulance patient handover delays.   

Our Pathways of Care Delays reporting framework provides all health and social care 
organisations with comprehensive monthly oversight of the key reasons for delays and 
recurring themes. Regions use this, together with wider population needs data, to identify 
local drivers of delay to help shape community service provision.  

The most recent data shows some monthly reductions in both the total number of delayed 
discharges and days delayed at an all-Wales level. In North Wales, there has been some 
fluctuation in discharge delay figures over the winter period which demonstrates there is 

 
 
 
 
 room to make further improvements. The Welsh Government is working with the regional 
partnership board to identify actions which can be taken to tackle local challenges, such as 
the trusted assessor models and Discharge to Recover then Assess (D2RA) pathways. 

To further support discharge and patient flow, we allocated £30m to local authorities via a 
new Pathways of Care Transformation Grant in 2025-26. Local authorities are using this to 
support timely discharge and prevent avoidable hospital admissions by strengthening 
community-based social care.   

There is some indication of improved capacity in domiciliary care in North Wales, with an 
increase in provision and fewer people waiting for support, although demand pressures are 
higher than in many other parts of Wales. Reablement delivery is broadly in line with other 
areas, although there is variation in reablement service models across local authorities.  

Additional support for Betsi Cadwaladr University Health Board 

Betsi Cadwaladr University Health Board is at the highest level of escalation – special 
measures – because we have serious concerns about how the health board is run; about 
the quality and safety of service; about the performance of services and about timely access 
to care.  

The Welsh Government is providing additional financial and expert support to the health 
board to help it make the necessary improvements to services. I recently announced a team 
of experts who will work alongside the executive team to focus on: 

•  Reducing ambulance handover delays and improving flow 
•  Reducing waiting times for planned treatment and diagnostic tests 
• 
•  Further strengthening governance, assurance, and leadership capability. 

Improving waiting times for cancer diagnosis and treatment 

The health board recognises the serious and multifactorial pressures facing the urgent and 
emergency care system in North Wales. The system is complex and requires a whole-
system approach to address increasing demands and to improve the accessibility, 
experience and outcomes for the communities it serves. Many of these challenges are not 
unique to North Wales and while the health board has made some improvements, 
significant transformation of services is necessary to deliver sustainable improvement.  

Thank you for this Regulation 28 report.  

Yours sincerely,  

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