Dear Dr Richards, Thank you for your Regulation 28 Report dated 141~ November 2022. In response to the inquest evidence and the concerns you consider a risk of future deaths, I have reviewed Maria's triage and management by the Out of Hours GP Service. I thought that it may be helpful to share with you the initial findings. I was concerned that this was not appropriately communicated with you at the inquest hearing and it may be that the poor communication on our part, had led to some of the recommendations in your regulation 28 letter. Initial contact was made by Mr Whale at 01:58, whereby the call handler took a broad summary of Maria's presenting complaint and demographics. The triage priority would have been assessed utilising the information imparted by Mr Whale, the decisions template deemed the call non-urgent which assigned a 60-minute call back. An attempt was made to call the land line, but the line was engaged. contacted Mr Whale at 03:13. The appropriate advice was given to call 999 for an ambulance for conveyance to UHW because Joanne recognised Maria was gravely unwell and her immobility meant there was no other way to transfer Maria to hospital, other than by an ambulance. From review of the calls it is clear that all possibilities for transference to EU were explored. It is noted that did ask during the call whether Maria had taken any pain relief. Maria had taken pain relief 20 minutes earlier and had a hot water bottle. I have attached a copy of the call transcription for reference. Thank you for your kind consideration.

Dear Dr Richards, Re: Maria lmmocalata Whale I am writing in response to the Regulation 28 Report that you issued to this Trust, dated 9 November 2022, following the sad death of the late Mrs Maria lmmocalata Whale. In the Regulation 28 you highlighted your concerns in relation to: "The 999 Emergency Service triage patients for priority depending on the response provided by a person close at hand to the patient, to a series of scripted questions. The Welsh Ambulance Service Trust has advised the following:
• Red calls are the highest clinical priority andare deemed immediately life threatening e.g. cardiac arrest;
• Amber 1 calls have a high clinical priority and are still considered a life threatening emergency e.g. chest pain;
• Amber 2 calls have urgent clinical priority, are serious but not considered immediately life threatening, for example diabetic problems; and
• Green calls are not considered to have urgent clinical priority and are not considered serious orlife threatening. Mae·r Ymdd riedoleeth yn croesawu gohebiaeth yn y Gymraeg neu'r Seesneg, ec na fydd gohebu yn Gymreeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding In Welsh will not lead to a delay

Anfonwch unrhyw ohebiaeth i'r cyfeiriad canlynol:­ Please forward any correspondence to the following address:­ Beacon House William Brown Close Llantarnam Cwmbran NP44 3AB FfOn/Tel 01633 626262

Mr. Whale in responding to these questions was advised his wife was not a priority. Clearly, the triage questionnaire did not adequately measure the gravity of Mrs. Whale's condition, as within two hours ofbeing graded a 'non-priority' she was declared life extinct. ". I do not wish to repeat the information that was already supplied to you within the statement from . She explained that the Medical Priority Dispatch computer based prioritisation System ('MPDS') is not considered to be a triage or diagnostic tool. The scripted questions are asked to establish the patient's condition at the time of the call. This allows the Trust to attend first to the sickest patient, at that time. At the end of each call, the caller is advised to call the Trust back, should the patient's condition change. This allows the Trust to reprioritise the patient should their condition improve or worsen. At this time the Trust does not intend to adjust the prioritisation questioning, as the issue is not so much the appropriateness of the questions but rather the harm caused by the Trust not being able to respond in a timely manner. At such times MPDS is supported by the Resource Escalation Action Plan and the Clinical Safety Plan. Resource Escalation Action Plan (REAP) The aim of this plan is to describe the arrangements in place to be considered by the Trust in response to a strategic or dynamic assessment of pressures affecting or likely to affect service delivery. The plan sets out a set of triggers based on various metrics that will identify pressure on service delivery and act as a guide to support decision-making. It outlines a categorisation of pressure on a scale of1 to 4 with associated actions for consideration. This categorisation is considered and set weekly by a group of senior operations managers. Given many of the actions that can be taken within REAP take some days to take effect this plan is designed to be a proactive forward looking tool to be used for short periods of additional pressure regardless of cause. It is not designed for sustained long term or permanent use at high levels of escalation. A copy of the plan appears as Appendix 2 to this statement. Clinical Safety Plan The Clinical Safety Plan (CSP) provides a framework for the Trust to respond to situations where the demand for services is greater than the available resources. It recognises that causes can be multifaceted impacting either demand for services, the capacity to respond to demand, or both. The CSP provides a set oftactical options that are flexible and immediate so that the Trust can dynamically react to situations to ensure those patients with the most serious conditions or in greatest need according to their presentation remain prioritised to receive services. 2

At its core, it achieves this by introducing a principle of 'can't send' so that available capacity when it is constrained can be targeted at those who need it the most, which results in some callers being advised that an ambulance is not available to respond. The level of CSP is constantly monitored, and decisions to escalate to higher levels are made by the Strategic Commander and depending on the level are supported through clinical and executive consultation. A copy of the plan appears as Appendix 3 to this statement. Background I am pleased to be able to provide you, below, with details of the actions that have been taken in order to reduce the lost hours and improve our response times to patients waiting in the community. I have also attached the most up to date action plan (Reducing Patient Harm Action Plan) Appendix 4. This plan has been presented and discussed at the organisation's Trust Board meetings since July 2022. The Trust is the national all Wales provider of 999 and Emergency Medical Services (EMS); 111 urgent remote clinical advice and Non-Emergency Patient Transport Services (NEPTS) with a workforce of over 4,000 and operating a fleet of over 700 vehicles from more than 100 premises nationwide. The Trust annual revenue turnover is more than £260m. During the pandemic the Trust has also nationally operated mobile COVID testing units. The Trust welcomes the opportunity to provide this response, which outlines the circumstances and nature of the Service's current operating context, the factors which have contributed to current pressures and the efforts the Service is making to alleviate those pressures. The issues outlined in this document are evidenced in the supporting data/information pack (Appendix 1 ). In providing this response the Trust Board acknowledges that H.M Coroners have, over several years, recorded Prevention of Future Deaths reports and other recommendations in respect of health services across Wales, including the Welsh Ambulance Service (the Trust). Such recommendations are taken extremely seriously by the Trust Board. In spite of the efforts made, there is an acknowledgement that progress in stabilising and improving ambulance service response times in Cardiff & Vale Health Board area, and indeed across Wales has not been as rapid, or as effective, as would have been wished. This response sets out several key issues which have served to adversely affect the Trust's performance in recent years, including during the Covid-19 pandemic, and particularly in the first half of the 2022 calendar year. It also sets out the steps taken to improve matters so far and the likely position moving forward. 3

The Trust is commissioned by the seven local health boards (LHBs) in Wales via the Emergency Ambulance Services Committee (the Committee) (EASC). The Committee is formed by the Chief Executives of the seven LHBs and presided over by an independent Chairperson appointed by the Health Minister. EASC has appointed a Chief Ambulance Services Commissioner (CASC) to undertake a lead role in supporting the local health boards in commissioning emergency ambulance services from the Trust within the context of the wider unscheduled care system (and, from 2016, Non-Emergency Patient Transport Services in Wales). The arrangements effectively create a commissioner/provider relationship in which the seven LHBs are collectively responsible for securing the provision of an effective emergency ambulance service for Wales. The Trust, therefore, is responsible for supplying the urgent and emergency medical services that the LHBs require, based on a commissioning framework. Commissioners set commissioning intentions on an annual basis reflecting the service standards and operational performance developments they expect to see. The Trust finances flow largely via EASC, with further monies coming either directly from Welsh Government or individual health boards, where they choose to commission additionality for their populations. Since October 2015, the Trust's clinical response model has been predicated on clinical outcome rather than target response time, save for its one formal target of responding in eight minutes to 65% (nationally) of calls which fall into the RED category, namely those which are categorised as immediately life threatening. Prior to the Covid-19 pandemic, national performance had generally been at or above target since 2015, although decaying performance had started to become apparent more latterly and there were geographic variances in performance that had not been entirely eradicated. Right-sizing the Organisation Against that backdrop of a gradual erosion of performance, in 2019 a national Demand and Capacity Review was commissioned. The review, which was led by world leaders in ambulance forecasting and modelling, Operational Research in Health (ORH), and was undertaken collaboratively on behalf of the Emergency Ambulance Services Committee (EASC), was itself an output of the Welsh Government's Amber Review published in 2018. The Demand and Capacity Review was carried out through 2019 and its outcome was formally reported to EASC in January 2020 where all of the recommendations from the review were endorsed. 4

One of the main findings of the Amber Review, was that many patients in the amber category of serious but not immediately life-threatening calls were waiting too long because of challenges relating to ambulance availability. The Review identified that the Trust had a gap between the number offull time equivalent (FTE) staff funded to fill its response rosters and the number of FTEs required to fill those rosters. This is referred to as the "relief gap". The ORH concluded that bridging the gap would require an investment of 263 staff on a full time equivalent (FTE) basis across Wales. The Emergency Ambulance Services Committee (EASC) agreed to invest in the Trust, over a two year period - 2020/21 and 2021/22, and close the "relief gap", while it was agreed re-rostering would help improve the alignment and mix of resources allied to patient demand. Throughout the pandemic, work continued to recruit the additional staff and progress with the roster review, as key planks in the Trust's response to the need to stabilise and improve pertormancelongterm. The Trust delivered an uplift in staff numbers in 2020/21 of 136 FTEs and 127 FTEs in 2021/22 with the final groups of staff concluding their training and becoming operational in Q1 22/23. In the same time period, the Trust agreed to take steps to reduce abstractions due to sickness absence, to increase 'hear and treat' rates (where patients are triaged and given advice rather than deploying an ambulance) to 10.2% and to implement new rosters across Wales. The ORH modelled that, with this additional resource in place, the Trust efficiencies delivered and a reduction in hospital handover delays to December 2018 levels, a national red response rate of 67.3% within 8 minutes and an amber 1 mean response time of 34 minutes would be achieved at the end of 2021/22. Performance Pressures There are several factors in combination which have led to the significant pertormance pressure under which the Trust now finds itself. In broad terms, these pressures can be defined as: a) Increased demand (particularly from the second wave of the pandemic in 2020 onwards} b) Higher acuity of patient - in part potentially a consequence of delayed presentation because of the pandemic c) Growing levels of workforce absence, both because of the Covid pandemic, and, increasingly, because ofenvironmental issues triggered by excessive delays at hospitals
- the concept of "moral injury" d) Excessive delays in the handing over of patients at hospital, a function both of increased demand across the system and of the paucity of social care provision (the reasons for 5

which are many and various), resulting in, at the time of writing, some 1,200 patients remaining in hospital beds across Wales when they are medically fit for discharge. This has led to chronic congestion within the hospital system and very poor patient flow resulting in delayed handover of care to Emergency Department staff upon arrival of an ambulance and thus delays in response in the community. Nationally in Wales, 999 call volumes have been increasing, and volumes weekly since October 2021 have generally exceeded the levels of demand compared to the previous three years (please see graphs in supporting data pack). Our forecast is currently one where volume continues to exceed previous levels of 999 demand. Within this demand are repeat callers who use 999 multiple times because of excessive waiting times in the community. We should note that this type of repeat call, often referred to as an Estimated Time of Arrival (ETA) call, is different to those that could be said to be vexatious. Since 2019, changes have been noted in demand patterns. There has been a notable increase in red demand, which shifts the overall acuity of the calls we receive and puts different pressures on resources. Importantly and generally, more resources per red incident are clinically required compared to other category of calls. As a result, further collaborative modelling has been undertaken by ORH which has confirmed that this change requires additional response capacity, specifically in terms of single responder I car capacity. In addition, the COVID-19 pandemic also had a significant impact, changing patterns of demand as the waves have progressed, and changing operational processes (for example the donning and doffing of personal protective equipment) which have impacted on response times and flow. As a service, it is acknowledged that absence rates are unsustainably high though patterns of increase do have strong correlation to the waves of the pandemic. Following the pandemic, and perhaps as a reaction to the unprecedented delays which staff are encountering at hospitals, rates of attendance are improving more slowly than we would ideally like. Significant investment has been made over recent years in the Trust's health and well-being offer for staff, which is now regarded as sector leading. This notwithstanding, absence rates remain stubbornly high although these are not out of kilter with other ambulance services across the United Kingdom. As a result, an extensive attendance management improvement plan has been developed with a range of measures aimed at improving attendance and supporting our people back to work. However, the "moral injury" reported by staff remains equally high, as the environmental stress of working under sustained and relentless pressure takes its toll. 6

Much of that "moral injury" is derived from the excessive handover delays at hospitals being experienced over very extended periods. With the entire health and care system under pressure and chronic congestion in hospitals, October 2022 the Trust saw some 36% of the national emergency ambulance capacity (Emergency Ambulance and Urgent Care Ambulance able to transport a patient) rostered to work lost and unable to respond to emergency calls as a result of delayed handover of care at hospitals. This results in several things: extremely poor patient and staff experience; extended waits in the community which result, regrettably, in some patients coming to harm; staff frustration leading to increased absence from work and diminished public and stakeholder confidence in the service. It is also recognised that there may be opportunities within some of the legacy operating practices for efficiency such as time lost by the Trust's own crews (post-production lost hours), for example when they return to base for meal-breaks. However, it should be noted that on average this takes 18.5 minutes on each occasion a crew returns to station for a rest break which given our extended geography doesn't present as unreasonable. The Trust has been working closely with its trade unions on this, and all of the issues outlined in this response, to ensure solutions are identified and delivered in partnership. Data specific to the Cardiff & Vale Health Board area are included in the data pack, but generally the data for this Health Board area is consistent with the all-Wales picture in respect of growing demand, excessive handover delay, acuity, and absence That being said, our colleagues in the Cardiff & Vale Health Board have undertaken a significant, and impactful, amount of work to address the issues facing both organisations, and we are seeing a marked decrease in the time our vehicles are at hospitals, allowing us to respond to people in the community in a more timely manner. The Trust will continue to work closely with our colleagues to build on these improvements. Patient Safety It is a sad fact that the cumulative effect of the performance pressures outlined above has a detrimental impact on patient safety. There is recognition across the United Kingdom that hospital handover delays cause direct and indirect patient harm and a poor-quality service. A recent structured clinical review of handover delays England wide was commissioned by the Association of Ambulance Chief Executives and published in November 2021. This review highlighted that 8 out of 10 patients waiting over one hour were assessed as experiencing some level of harm, with just less than 1 out of 10 patients classified as experiencing severe harm. Welsh Ambulance Service NHS Trust - AACE report on hospital handover delays: Statement from the Chief Executive (wales.nhs.uk) 7

The Trust has an incident reporting and investigation process in place, aligned to the NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. A multidisciplinary panel meets at least weekly to review all patient safety incidents assessed as potentially causing serious or catastrophic harm. Internal investigations are undertaken to identify learning opportunities and improvement actions are subsequently developed and implemented. The Trust is recognised by Health Care Inspectorate Wales as having a strong culture of reporting harm, with Nationally Reportable Incidents (serious incidents) (NRls) being reviewed both via the Trust's Serious Case Incident Forum (SCIF) and being reported nationally to the NHS Wales Delivery Unit. A significant proportion of NRls are also shared by the Trust with health boards for joint investigation, particularly where handover delays/long community waits are deemed to be a pertinent factor in the outcome for the patient and/or their poor experience. Where an emergency department handover delay is considered a primary causation of a /National Reportable Incidents (NRI), the details of the incidents are provided to the Health Board using an agreed transfer process known as the Joint Investigation Framework, formally known as "Appendix B". During 2021 the NHS Wales Delivery Unit undertook an analysis of 'Appendix B' reports, submitted by the Trust to the Health Boards. The analysis focused on identifying any trends or themes of potential patient harm caused by the Trust's inability to respond to calls due to NHS Wales system pressures. Findings from the analysis included: a) 'The most common contributory factor detailed in the Appendix B is handover delays, where WAST resources are delayed in handing over patients upon at hospital sites in keeping with nationally agreed handover timescales'. b) 'Given that in 71 (84% of) cases the outcome has been death, with the vast majority of these deaths occurring prior to WAST, the data indicates that the window of opportunity to provide medical assistance to seriously unwell patients in the community, classed as Amber 1 calls, is being routinely missed, and likely on the balance of probability to be a causative factor in the timing of patients death, given they were alive at the initial call but deceased upon arrival 6.5 hours later (on average)'. Similarly, all Health Boards receive quarterly reports on quality and safety incidents as they relate to their areas and populations, for whom they have population health responsibility. At the time of writing, the issue of patient safety is very high on the Trust Board's agenda, with its committees considering a number of papers evidencing harm and expressing their concern about the safety of patients in the current operating climate. I have attached the most up to date action plan (Reducing Patient Harm Action Plan). This plan has been presented and discussed at the organisation's Trust Board meetings since July 2022 and most recently in November
2022. 8

It is the risk to patient safety which is the Trust's key driver in redoubling its efforts with Welsh Government, commissioners and other stakeholders to drive real improvements at pace. Healthcare Care Inspectorate Wales (HIW) undertook an inspection of the Trust and published their report 'Review of Patient Safety, Privacy, Dignity and Experience whilst Waiting in Ambulances during Delayed Handover' which covered 1 April 2020 and 31 March 2021. The inspection covered all Emergency Departments (ED) across Wales. Recommendations from the report include: a) Health Boards and Welsh Government should consider what further actions are required to make improvements regarding the patient flow issues impacting on delayed patient handover. This may include consideration of whether a different approach is required by the Trust, Health Boards, and social care services within Wales, to that taken to date in tackling this system-wide problem. b) Health Boards should consider the benefits of the introduction of specific roles within their EDs that have the aim of improving process the handover of patients from ambulances. c) Health Boards must ensure that appropriate representation is present at the Trust's Serious Clinical Incident Forum meetings, to aid with the timely management of concerns and service improvement. Following publication of the Report the Emergency Ambulance Services Committee (EASC) recently set up a task and finish group chaired by the Deputy Chief Ambulance Services Commissioner to respond to the recommendations. The membership of the group is determined locally but should as a minimum consist of clinical and operational representatives from each of the 7 Health Boards. Membership also includes representatives from the Trust and Welsh Government. Addressing the Issues It is fully acknowledged that the issues confronting the health and care system are not easily resolved. That said, the safety of patients is, at differing points, compromised because of system pressures and the Trust Board of the Welsh Ambulance Service recognises that this is unacceptable. As a result, a number of actions have been put into place to try and mitigate risks to patients, with variable levels of success, while wider system and governmental conversations are now in an acute phase at the time of writing following escalation by me and other senior officers at the Trust. 9

Detailed below is a brief overview ofthe actions which have been taken (in addition to the REAP and CSP mentioned earlier in this letter) or proposed to commissioners, by the Trust, in a bid to alleviate the current pressures. Seasonal planning including forecasting As well as utilising the services of ORH in longer term demand and capacity modelling, the Trust also commissions services from Optima who use simulation models which can predict output performance based on a range of input assumptions. Through the pandemic period, the Trust worked hard to improve its shorter term forecasting, and produced quarterly reports which set out what performance is likely to be, given a series of assumptions around demand and available capacity. The accuracy of these reports has been good, and they have been used within the Trust and in discussions with commissioners, to develop mitigating action plans where performance is forecast to be below that required. Additional Capacity Throughout the period of the pandemic, additional Urgent Care Service capacity has been provided through an agreement with St John Ambulance Cymru. This has been financially supported by our commissioners wherever possible and concluded at the end of March 2022 without ongoing financial support. During the periods of extended hospital handover delay that the Trust is experiencing, this initiative enables frontline crews to offload patients to appropriate clinicians in order for vehicles to be available and respond to waiting calls in the community, and ensuring that patients receive a more timely response which results in reduced patient safety incidents and improved patient experience. Voluntary overtime remains available for all operational/clinical staff across the Trust without financial restriction and whilst uptake has reduced in recent months, largely as a result of the current workplace experience, we continue to see in excess of 5,000 hours per week being worked. Controls to restrict the overall spend on overtime may need to be introduced as the year proceeds should the financial position require it. Roster review The roster review, as agreed as part of the Demand and Capacity Review, has now concluded. The review was supported by an external company, Working Time Solutions (WTS), who are experienced in these reviews across other ambulance services, other public sectors and industry. The work progressed through a series of four working parties in each local area, attended by front line staff, managers, resource team and trade union partners. Roll out of the new rosters commenced in September 2022. 10

The roster review process was paused in 2021/22 whilst additional modelling was undertaken to understand the impact of the increases in red demand and a further decay in emergency department handover lost hours. The outcome of that modelling was that further single staffed car capacity was required, totaling 90 WTE additional staff, and this has now been built into the new rosters. Commissioners have agreed that the modelling is correct, but no additional resources have so far been made available for 2022/23, which means that the new rosters will initially operate with an inbuilt relief gap. Roster Review Project - C&V FTE Staffing as at time that
149.3 the Demand and Capacity Review (including Paramedics, EMTs and ACA2 staff) FTE staff currently
146.96 (paramedics and EMTS only) Estimated FTE ACA2. staff
36.83 currently being recruited (end of January 2023) Total estimated FTE staffing
183.79 by end of January 2023 Uplift
34.49 FTE (23%) Escalation WAST Operational Delivery Unit The Operational Delivery Unit (ODU) acts as a central hub providing coordination for the Welsh Unscheduled Care System with a link between the Trust, Welsh Government, and all the Health Boards through a system-wide view. The purpose of the ODU is to keep the unscheduled care system in Wales flowing by supporting existing internal and external operational management arrangements. It provides a management overview of the Trust and broader unscheduled care system delivery by monitoring and reacting to real time performance inhibitors that challenge timely and effective patient care. 11

The ODU currently has four main areas of focus to achieve this purpose; to maintain pan-Wales situational awareness, to consider performance, limit post-production lost hours and plan for the upcoming 24 hours. Alongside the four areas of focus, the ODU has three main objectives to ensure system wide performance. a) Pre-empt: Identify and analyse potential risks and issues over the next 24hours and current trends b) Mitigate: With the aid of local teams, develop actions to mitigate or negate any identified risks/issues c) React: Dynamically react to situations as they unfold and take decisions on whether to react System and Peer Groups The leadership team of the Trust has taken every opportunity to escalate concerns across the system over a period of months. Professional leads, peer groups, and government have been apprised of the risks, harms and challenges in various forums in addition to formal reports and correspondence, while commissioners have been presented with the same and a currently unsupported Transition Plan (see below) to try and ameliorate the worst of the performance issues and attendant harms. The Trust also uses regular media and stakeholder briefings to explain the issues, both to encourage appropriate use of urgent and emergency healthcare by patients while ensuring stakeholders are sighted on the issues and what is being done to mitigate harms and improve performance. Similarly, partnership groups, including Regional Partnership Boards where the Trust is a member, have been apprised of the issues and early conversations with local authorities in particular are progressing (subject to capacity constraints on both sides) to identify collaborative opportunities to reduce conveyance and improve the experience of patients. Transition Plan The Trust is committed to doing all that it can to reduce clinical risk, improve patient care and outcomes, ensuring that patients get the right service, in the right place, every time. The data in support of this statement shows that there is much more to do, with some actions within the Trust's control, and many which are outside of its control. As a result of concerns about clinical risk and patients coming to harm, the Trust developed a Transition Plan, which was submitted to commissioners in December 2021. In essence, this plan was a bid for investment, as well as setting out the actions to be taken within the Trust to continue to improve efficiency and to transform its delivery model. 12

The case proposed additional investment to increase front line capacity by around 300 FTE across the Emergency Medical Service (EMS), including Advanced Paramedic Practitioners (APPs). The proposed investment, building on previous investment, together with the delivery of a series of changes and efficiency improvements commenced over the last two years, would provide a range of significant benefits: a) an increased capacity and resilience in our existing service provision to meet the needs ofthe population ofWales in a safe and timely way, improving outcomes for patients and reducing clinical risk and harm; b} an improvement in the working lives of our frontline staff, alleviating the causes of stress and sickness and further improving our ability to provide the required capacity; c) a transition away from the traditional model of ambulance services, towards a transformed state in which patients are increasingly treated at or near home, avoiding unnecessary conveyance to an Emergency Department (ED), improving patient outcomes, and relieving pressure within the urgent and emergency care system; d) a realignment of resources, ensuring that their value is maximised in the most effective and efficient way to meet patient needs. Undertaking the above actions are principally based around protecting the services ability to respond to patients whose presenting condition require a timely ambulance response, by ensuring that as many patients as possible are managed in a setting away from secondary care. Significant pressures within the 999 service in the last 12 months have led to very poor patient experience and outcomes, with response times lengthening for all categories of patients, and too many patients coming to serious harm as a result. The Trust has also had to deploy its Clinical Safety Plan more often than it would want, and at times, has been unable to send any ambulance response to patients in lower acuity categories, adding risk to patients and to other parts of the urgent and emergency care system. Despite the proposals being put forward by the Trust, to-date the Transition Plan remains unfunded although, at the time of writing, discussions continue with commissioners and government. Closing Observations The pressure facing the Welsh Ambulance Service and the wider health and care system are sustained, extreme, and not new. They are issues which have been evident for far too many years. The recent pandemic and its impact has thrown into sharp relief the fragility of that system and, with competing priorities around urgent, unscheduled and planned care, health boards and government are having to manage multiple issues at a time when there is limited capacity, 13

energy and resources to drive forward solutions in the quantum required to make a sufficiently significant impact. All partners, whether in health or social care, recognise that something needs to be done differently, and all acknowledge that patients/clients are the net losers in the currently overheated system. As an ambulance service, we recognise that there are issues within our gift to resolve (e.g. attendance, post production lost hours) and there are tangible plans in place to address these. All these actions, the quantum of which remain insufficient to offset system wide inefficiencies, at best demonstrate that the Trust has considered every possible way in which we can react to and mitigate the impact of these pressures, which are fundamentally outside of our control. Taken together, the Trust Board believes the organisation has taken all possible steps to manage and mitigate the impact of acute system pressures, including those which are beyond our control but impact on our ability to respond in a timely way or provide patients with the experience they have a right to expect. However, there are no easy answers. The key issue will be the pace and urgency with which the system can respond to the matters at hand, recognising that, following repeated WAST escalation, this is now starting to gain traction. While significant collaborative work continues to be undertaken on these issues, there is little that the ambulance service can fundamentally do to insist on discrete actions, beyond lobbying and highlighting the very significant patient safety concerns which arise, particularly from extended waits outside hospitals, which inevitably also result in excessive waits for those patients awaiting help in the community. Similarly, the role of Welsh Government will be considerable both in terms of resourcing and policy direction if we are to see the real and tangible shifts away from a hospital and conveyance model of care, to one which really focuses on upstream and community-based models of integrated care. The Trust will continue to press for real systemic change at every opportunity and continues to do its very best to deliver a consistent service at a time of significant societal difficulty. To conclude, our response to Mrs Whale is not the level of service that we want to provide for the people in Wales. I hope that this response has provided you with a level of assurance that we, as an organisation, are doing everything in our control to reduce the level of risk, harm and the impact that the system pressures are having on patients in our communities, waiting for ambulances over an extended period. Whilst writing I would like to extend my sincere condolences to Mrs Whales's husband and wider family on their sad loss. I would also like to extend the offer to meet with you to discuss our 14

response in more detail and provide you with any further assurance you may require regarding our commitment to continual improvement to support the prevention of future deaths.