Dear Mr Barkley Re: Ceriann Richards (Deceased) I write further to the receipt of the Regulation 28 Report in respect of the Inquest heard into the death of the above named person_ The ability to release ambulance crews in order to respond to community calls is of paramount importance to the Health Board. We have taken a number of steps to address these issues and have ongoing work at present, Breaking the Cycle' , which is focussing resources on processes to support the patient journey. As a Health Board have implemented and reviewed a number of processes An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing governance and assurance to the Board. A Standard Operating Procedure has been implemented which supports bed management and site management teams in utilising all bed capacity across both Nevill Hall Hospital (NHH) and Royal Gwent Hospital (RGH) when ambulances are in danger of being held outside of our Emergency Departments (ED): This protocol was adopted by the Health Board's Urgent Care Board and is part of the Health Board Escalation Process, which was reviewed and re written in preparation for winter 2016/2017. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc's Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffon; 01633 234234 Tel No: 01633 234234 Bwrdd lechyd Prifysgol Aneurin Bevan Yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board key we

Mr Andrew Barkley 20 April 2017 The Health Board has identified escalation protocols which are used to guide ED staff in the operational procedures for receiving and off-loading ambulances: These include a preparatory escalation when more than three crews are on site and limited capacity exists to off load further ambulances, predicted to arrive_ This escalation is to the bed management teams who are required to move patients from ED to the available bed capacity with immediate effect. The Health Board has a Red Release Protocol for response to Welsh Ambulance Services NHS Trust (WAST) when a crew is required to attend Red' call in the community_ This protocol has been worked through with WAST colleagues who meet with Health Board Operational Managers each fortnight to discuss operational issues and address any concerns_ The Health Board has a Winter Resilience Plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure This plan is shared with all local stakeholders and partners to ensure the actions and initiatives described within the plan are shared and agreed prior to implementation. The Health Board has continually reviewed the plan on month by month basis at its Urgent Care Board_ This has led to a number of actions being reinforced since the implementation of the plan to ensure more robust response to ambulance handover pressures. The following data clearly illustrates the impact that the escalation processes and protocols have had on reducing ambulance hand over times and delays >lhr at the Health Board this winter. NOV-DEC JAN MAR AMBULANCE HOURS LOST 2016/17 1178 2014 2015/16 1183 3002 % CHANGE 1 %
-33% AMBULANCE DELAYED 1HR 2016/17 412 739 2015/16 443 1133 % CHANGE 7% 35% Since 23 March 2017, Aneurin Bevan University Health Board has been introducing Breaking the Cycle' , an initiative which is looking at processes to support flow within the acute hospitals, ie timely discharge, appropriate placement and timely transfer of patients from the ED and MAU.

Mr Andrew Barkley 20 April 2017 This has seen the implementation of two transfer teams, one transferring out of the wards and one transferring out of ED. Discharge facilitators have also been introduced on each of the wards at RGH. There is work is commencing to implement this model in NHH_ Breaking the Cycle has led to improved patient flow within the hospital, reduced congestion in our EDs and has led to a consistent approach over seven days a week. The actions implemented by the Health Board have been captured in the attached action plan. Please be assured that these actions and their impact on ambulance handover performance are monitored by the Health Board. I do hope that this information and the action plan attached (developed in partnership with WAST) give the assurance that we, as a Health Board, are focussed on the patient flow and are actively working, in partnership, to reduce ambulance delays in our Emergency Departments and Assessment Units, to ensure that our citizens receive timely appropriate response in the community_

Dear Mr Barkley,

Regulation 28 Report to Prevent Future Deaths – Ceriann Richards

Thank you for your letter to the Minister for Social Services and Public Health regarding the regulation 28 report following your investigation into the death of Ceriann Richards. I am responding on behalf of the Minister. I would also ask that you please pass on our condolences to the family of Mrs Richards.

You raised concerns regarding significant hand over delays within two district hospitals in the Aneurin Bevan University Health Board areas, resulting in the delay of an ambulance being dispatched. We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service’s ability to respond to subsequent calls in the community, but also on patient’s experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital, improving patient flow through the hospital system and enabling greater capacity in the community to support timely discharge.

The Welsh Ambulance Services NHS Trust has made progress in limiting conveyance rates to hospital through the development of a five-step ambulance patient care pathway and focus on initiatives that help patients who have dialled ‘999’ to remain at home or to access a more appropriate service for their needs. This has included:

 the enhancement of its clinical desk, where paramedics and nurses provide secondary triage to patients who may be safely discharged over the telephone or advised to make their own way to hospital (known as ‘hear and treat’);  establishment of alternative pathways for a number of conditions;  a falls response service; and  a frequent callers project which has significantly reduced unnecessary call demand

The NHS Wales Ambulance Availability Protocol, published in March 2016 is also subject to review by the Emergency Ambulance Services Committee (EASC) in light of concern raised in relation to its effectiveness.

The Welsh Ambulance Services NHS Trust (WAST) and local health boards have shared responsibility for ensuring the safe and timely handover of patients from ambulance crews to hospital teams and I expect health boards and WAST to continue to work together to reduce handover delays and to divert demand around the system during busy periods as well as improving patient flow through hospitals