Dear Ms Knight,

Re: Richard Thomas Peter Barrett (deceased)

This is a response to the Regulation 28 Report to Prevent Future Deaths that you issued to Cardiff & Vale University Health Board (the Health Board), the Minister of Health and the Welsh Ambulance Services NHS Trust (the Trust) on 30th July 2018 following the conclusion of the inquest for Richard Thomas Peter Barrett.

The Welsh Government will respond to you separeatley. This is a joint response from the Trust and the Health Board. Within your report you asked the Trust and the Health Board to consider and address the following specific issues:

a) Demand Analysis and its fitness for purpose and b) Provision of adequate ambulance and call handler resources in a growing city.

As described at the Inquest the Trust currently uses previous year’s emergency demand profile, with a percentage uplift when trying to predict the daily emergency demand.

In addition the Trust’s Planning & Performance Directorate since July 2018 have been working on a project in relation to Optima Predict.

Cadeirydd Dros Dro/Interim Chair: Martin Woodford Prif Weithredwraig Dros Dro/Interim Chief Executive: Patsy Roseblade Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg The Trust welcomes correspondence in Welsh or English

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Optima Predict is a powerful interactive strategic planning solution for Emergency Medical Services (EMS) that provides a platform for effect the Trust an in-house capability to undertake work like the Operation Review Demand & Capacity Review.

Optima Predict takes into account key performance indicators (KPIs) such as response times, vehicle coverage and shift requirements and allows users to quickly build scenarios that make logistical and business sense. It can be used to estimate call volumes, for the coming year and beyond, test different coverage and posting plans, test proposed roster changes and then analyse their impact, enabling the Trust to select the most effective option and take action.

The project is ongoing and the Trust is currently modelling the plan for Optima Predict and the issues that will be selected for analysis. I hope this reassures you that the Trust is taking action to address and further strengthen future planning by using this software.

The use of the software will assist the Trust in planning the utilisation of available resources to inform our Integrated Medium Term Plan.

The Trust has also undertaken the recruitment of 90 additional staff, who are undergoing training and will be operational by December 2018. Whilst the increase in staff is pan Wales, a proportion of the new staff will be operational in the Cardiff and Vale area. This will enable the Trust to increase the number of staff available.

c) The process of making, and timing of welfare calls, particularly in overdose cases.

Currently the documentation on management of welfare calls is part of the Trusts Resource Escalation Action Plan (REAP) and Demand Management Plan (DMP) for the Clinical Contact Centres. This states that welfare calls should be made when Red calls are waiting more than 8 minutes with no resource allocated, when Amber calls are waiting more than 20 minutes with no resource allocated, when green calls are waiting more than 30 minutes with no resource allocated and when Health Care Professional calls have had no resource allocated within the agreed timeframe.

The welfare call is undertaken by an identified member of Clinical Contact Centre (CCC) staff from either the call taking or dispatch function depending on who has the most capacity. The Demand Management Plan identifies that ‘It is recognised that delays are often a reflection of demand and as such capacity to undertake a robust welfare call procedure is challenging. Every effort should be made to facilitate this process to maintain good customer practice where possible’. All callers are informed to ring back if the patient’s condition deteriorates.

If there is no answer on a welfare call the Demand Management Plan instructs the incident should be referred to a registered clinician on the clinical desk for

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a decision on whether the response should be upgraded. At times of high demand when incidents are polling waiting for a resource the Clinical Support Desk Shift Lead will also review calls or allocate a clinician to review a specific category of call.

Following this specific incident an email was sent to the Clinicians on the Clinical Support Desk on the 15th May 2018 by the CCC Clinical Lead. The email identified the importance of attempting to review protocol 23 (overdose) calls when there were delays in responding as these may be time critical. If there was no reply the clinicians should use their critical thinking skills to determine how likely unconsciousness or death would be based on what the patient is recorded as having taken and act accordingly.

The advice of the Clinical Control Centre Technical Manager has been sought and she has confirmed that unfortunately currently there is no searchable way of identifying if the patient is on their own. The queue also cannot be filtered to a specific protocol, however it is possible to view the codes whilst the incident is waiting on the Recall Waiting Call queue and as mentioned cases relating to overdose will have a code that starts with the number 23.

d) Turnaround delays at the major hospitals and the unrealistic target.

The Health Board and the Trust work closely together to minimise delays in hospital handover and ensure patients receive the care they need in a timely manner. In common with most hospitals the Health Board can experience occasions when the number of ambulances arriving at the emergency unit temporarily exceeds the capacity of the unit to safely receive the patients, leading to a delay in handover from the Trust’s crews. We are very aware that these waits are not only sub-optimal for the patient on the ambulance at the time but can also affect the ability of the Trust to respond to patients in the community. For these reasons we endeavour to keep these delays to an absolute minimum and closely monitor our performance on an hourly and daily basis.

Over recent years the Health Board has made significant changes in its unscheduled care system, including substantial investment. These have included: an increase in the Emergency Unit (EU) medical and nursing workforce, the establishment of an Ambulatory Emergency Care (AEC) unit, the commissioning of three additional resuscitation bays, an increase in emergency theatre capacity, an expansion of the Frail Older Person Assessment and Liaison (FOPAL) service, a redesign of the Emergency General Surgery and Urology services to provide a dedicated consultant daily, and an increase in critical care capacity.

In addition the Health Board has worked with its regional partners, including the Trust, to redesign the unscheduled care system seeking to reduce the need for emergency conveyance, attendance and admission and implementing

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alternative pathways of care. These have included preventative initiatives with the local authorities, support for care homes, a frequent attenders programme, investment and skill mix changes in GP out-of-hours, the establishment of a community assessment unit, the expansion of the community resource team (CRT) to seven days/week, and the development of Trust’s pathways aimed at reducing the number of ambulance conveyances to the emergency unit (including the use of taxis where appropriate).

During the winter months it is recognised that the demands on the unscheduled care system can be significantly higher and more variable than at other periods. The Health Board leads on the development of a regional integrated winter preparedness plan for Cardiff and Vale jointly produced by the partnership organisations: the Health Board, the Trust, Cardiff Council, Vale of Glamorgan Council, Cardiff Third Sector Council and Glamorgan Voluntary Services. This plan seeks to coordinate the preparations for winter to anticipate and mitigate the impacts of winter pressures as best this can be achieved within the constraints of the system.

Throughout the year the staff within the Emergency Unit work closely with Trust colleagues to respond dynamically to the operational demands and maintain safe levels of care. Senior managers from both organisations meet on a monthly basis to address any operational issues raised and identify opportunities for improvement.

The unscheduled care system is complex, multi-factorial and often highly variable. In the case of Cardiff and Vale it operates within an environment of both an ageing and a rapidly growing population. The impact of this can be seen in the EU data with attendances in 2018 (January-July) up 1.8% on 2017 and 9% higher than 2015. By contrast ambulance conveyances have actually reduced reflecting the positive impact of the work described above and within the Trust.

As described, minimising ambulance handover delays is a particular focus for the Health Board and the Trust. Despite a difficult winter period the total number of lost ambulance hours reduced during 2017/18 by 5% (prior to winter the improvement was running at 20%). In recent months the Health Board has established two-hourly safety and performance huddles in EU to closely monitor the status of the unit (including any ambulances waiting outside) and proactively respond to any build-up of pressures. This has contributed to continuing that improvement trend since the end of winter, with July 2018 having the fewest handover delays of any month for three years.

The Trust also continues to try and avoid admission of patients to the Emergency Department when it is safe to do so. Whilst the following actions do not directly affect how long ambulances take to hand over the care of patients

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when they arrive at hospitals, these actions see a reduction in the number of patients attending Emergency Departments across Wales and improve the flow of patients within the NHS. Please find appended to this response some details of these supporting actions.

e) Asking the police to undertake a welfare check in an overdose case, where the patient is alone and an ambulance is likely to be hours away.

We have a memorandum of understanding with the Police which does specify circumstances in which the Trust should contact the Police. Welfare checks are not included within that document. The Trust does meet with the Police as part of the joint emergency services network. The Trust will raise this issue with the Police at these joint meetings and seek an increase to the specific circumstances to include overdose cases. We will write to you further once that meeting has taken place and update in relation to the matter.

It may not be possible for the Trust’s systems to identify cases where a patient is alone and the request may need to be made in all cases, rather than just situations where the patient is on their own.

In summary we would like to confirm that the Trust has and will continue to action the following:

 CCC Clinical Leads have been reminded that Protocol 23 cases should be dealt with in a timely manner.  The Trust will approach the Police with a view to formally extend the MOU to include overdose cases.  Expansion of the clinical desks.  Rolling out the APP model across Wales  Implementation of Level 1 response to people who have fallen and are not injured.

We would like to reassure you that the Welsh Ambulance Services NHS Trust and Cardiff and Vale University Health Board continue to work together to drive the improvements and learning forward that we had commenced last autumn and we continue to strengthen the out of hospital alternative pathways to improve efficiency and effectiveness of care for our patients and make best use of our resource.

We hope that we have been able to assure you that we continue to work collaboratively to improve services together and that actions taken to date have had an impact in relation to all of the areas identified within this Regulation 28 Report, namely improving our response to people in the community, avoiding patients being conveyed by ambulance to the Emergency Departments, increasing the capacity of appropriate resources and assisting in patient flow.

We would like to extend the offer to meet with you to discuss our response in more detail and to provide you with assurance of our commitment to the continuous improve our service provision.

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Dear Ms Knight,

Regulation 28 Report to Prevent Future Deaths – Richard Thomas Peter Barrett

Thank you for your letter enclosing the above Regulation 28 report following your investigation into the death of Richard Thomas Peter Barrett. I’m responding on behalf Vaughan Gething Cabinet Secretary for Health and Social Services. The Welsh Government expects the Welsh Ambulance Services NHS Trust (WAST) to plan and deliver a safe and timely service to the people of Wales, based on an assessment of demand, ensuring there is sufficient staffing and resource cover in its clinical contact centres and in the community to meet demand, and to flex capacity at times of increased pressure.

WAST has reported that at times of increased demand, capacity to undertake welfare calls is reduced and it is currently considering options to increase capacity on its clinical support desk which provides support and advice over the telephone, as well as opportunities for third sector organisations and other agencies (e.g. Police, Fire and Rescue Services) to support the delivery of welfare checks, particularly for patients who have experienced a delayed response.

In April of this year, the Cabinet Secretary for Health and Social Services commissioned the Chief Ambulance Services Commissioner to conduct a clinically-led review of the ‘Amber’ category, which includes serious, but not immediately life-threatening calls and accounts for around 65% of call volume to the Welsh ambulance service. The review is being undertaken alongside ongoing work to improve ambulance responsiveness, clinical outcomes and patient experience in order to make sure patients continue to get the most appropriate and best level of care and treatment for their needs. It is due to be completed at the end of this month and the Cabinet Secretary will be making a statement to inform Assembly Members on how its findings and recommendations will be taken forward in October.

A key part of the review is an examination of patient risk across the pre-hospital patient pathway. This includes analysis of patient-level linked information across the pathway as well as serious incidents and Coroners’ reports to identify opportunities for learning to be applied to inform the review’s recommendations.

The review is also looking at expectations and experiences of the public, staff and the wider service around ambulance response. This will include the extent to which members of the public are supported and kept informed when making a 999 call. In this respect, the review may deem it necessary to make recommendations around continuity of care through increased welfare checks for all relevant calls and other options to reduce anxiety of those waiting for an ambulance to arrive.

The Welsh Government recognises the challenge caused by lengthy handover delays at emergency departments, which we know can impact not only on patient experience, but also on the ability of the ambulance service to respond to subsequent urgent calls in the community.

We expect health boards to monitor all patients, especially those with time-critical and acute conditions or injuries to ensure they are handed over to the care of specialist staff as soon as possible, in order to improve patient outcomes and manage the associated risk. The Cabinet Secretary has also been clear with health board chief executives that they must take responsibility to reduce and eradicate patient handover delays by working with the Welsh ambulance service and partner organisations to improve patient flow through hospitals and receive patients from ambulance crews in a safe and timely manner. In addition they must explore alternative pathways and be able to divert demand to other unscheduled care services to reduce pressure at emergency departments during busy periods.

It should be noted that there is no time-based target for the handover of patients from ambulance crews to emergency department staff. However, the Welsh Health Circular on NHS Wales Hospital Handover Guidance, published in May 2016, sets out good practice for patient handover, including an expectation for patients to be handed over within 15 minutes. Officials continue to monitor patient handover delays closely on a daily basis and challenge health boards where appropriate.

I do assure you that Welsh Government will keep this case and the learning that arises under ongoing review.