Dear Mrs James Re: Diane Greenslade (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. We were extremely saddened to hear the details of this case. The ability to release ambulance crews in order to respond to community calls is of paramount importance to Aneurin Bevan University Health Board (ABUHB) and we are working closely with our Welsh Ambulance Services Trust (WAST) colleagues ts iprove handover delays: Ambulance services are measured on the time it takes from receiving a 999 call to a vehicle arriving at the patient's location. Life-threatening and emergency calls, under the current standards, 65% should be responded to in eight minutes: In December 2017, ABUHB region achieved 63% against this target; which we recognise is unacceptable: However, with the recent work that has been introduced, this response improved to 71% in December 2018. Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board 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 436700 Tel No: 01633 436700 E-bost: abhb enquiries@wales nhsuk Email: abhb enquiries@wales nhs.uk NHS GIG Bwrdd Iechyd Pritvsgol Aneurin Bevan Vw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operationa name of Aneurin Bevan University Local Health Board 00

Ms Wendy James 2 25 January 2019 As a Health Board, we have reviewed and implemented a number of processes which should, in turn improve the timeliness of releasing crews at the hospital: The Health Board has identified escalation protocols which are used to guide staff within the Emergency Department (ED) in the operational procedures for receiving and offloading ambulances. These include escalation when 3 or more crews are delayed for greater than 30 minutes and limited capacity exists within the hospital to off load them. At this stage, the nurse in charge of ED will transfer stable patients from the majors department to the minors department to create capacity for crews to bring their patients into the department This is then a trigger to the site manager to move patients from ED to any available bed capacity with immediate effect, or to pre-emptively move towards where there are any upcoming discharges: The Health Board has a Full Capacity Protocol which lists a number of objectives to guide staff to trigger a list of actions, with the overall objective , to secure and maintain the safety of patients and staff within the ED and Assessment Units: This is to allow patient moves which facilitate the immediate handover of ambulances: The Health Board also has a Red Release Protocol for response to WAST, for when a crew is required to attend a 'red' call in the community. The identification of 'red release' bed is discussed and agreed at, each operational site meeting and a patient is identified as the urgent next move from ED, should the need to respond to a red release is called. There are times when our Emergency Departments do struggle to offload ambulances back into the community. We try to make provision at these times. One of these is during the pressures associated with winter . 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. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on weekly basis and also reviewed and monitored by the Health Board's Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital: For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting: We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital: We have additional doctors in the Emergency Department and on our Assessment Units to ensure more timely assessment of patients, and we have opened additional capacity in order to meet the predicted demand: There are several other initiatives to support the winter pressures to reduce demand, and improve our flow in order to release ambulances_ key

Ms Wendy James, 3 25 January 2019 I appreciate that the handover delays was crucial in Mrs Greenslade's case and were extremely saddened to hear that this was found to be the case; I do hope that this information gives the assurance that we, as a Health Board are focussed on the patient experience and actively working in partnership to reduce ambulance delays in our Emergency Departments and Assessment Units.

Dear relating writing Trust '9545149

Training of relevant Clinical Contact Centre staff Recruitment of clinicians within the Clinical Contact Centre Aligning production against demand both locally ad time of day. This means ensuring we have the right levels of staff availability to meet the demandeaith which we are faced Reducing the duration of handover to clear ie the time it takes for our staff to become available following the handover of a patient to another care providerg generally hospital staff Introducing safe alternatives to responding to scene, where this is appropriate Reducing conveyance where Safe and appropriate, and providing care pn ahe patient's home utilising advanced practitioners reduction in sickness absence In addition to the accompanying action plan, the continues with other improvement initiatives designed to safely release resources to respond totpetientalitn greatest need_ This includes the introduction of our Falls Framework and increasing the scope of practice for our Community First Responders would like to share with You some details of the Trusts Falls Framework and the recent development of a more Structured response to people who have fallen in the community, as it is relevantto the circumstances surrounding the fall that Mrs Greenslade experienced. Falls Framework and Falls Response Model During the third quarter of 2018 19, the Trust; working in partnership with St John Ambulance Cymru Wales, has implemented the role of the Falls Assistant across fve health boards: Aneurin Bevan University Health Board Abertawe Bro Morgannwg University Health Board Cwm Taf University Health Board Cardiff & Vale University Health Board Hywel Dda University Health Board Level 1: Falls Assistant Role The Falls Assistants provide an initial response to safely lift patients where there are no injuries, or a minor injury, as a result of a fall. The Falls Assistants will be in their assessment of the patient by a paramedic or nurse working Omeheooiced Support Desk in ur CCC, who will offer clinical advice and support: A Falls Assistant can be a member of Trust staff from our Urgent Care Service, voluntary Community First Responder, Or in partnership with other agencies, employed by another organisation such as St John Cymru Wales or the health board; There are now seven Falls Assistant schemes working across Wales providing support Trust sadly

across five health board areas: During October- December 2018 the teams 771 patients across Wales. In North Wales we have developed attended a model with our Community First Responders where we have 10 teams working across the region . Level 2: Possible Injury_FalComplexity-Falls Response Service A Level 2 falls response is required either where it is unclear if there is an injury or not or where the person has co-morbidities or complex needs A level 2 multi-disciplinary team can undertake response is where comprehensive assessment of the person ine their own home and implement an appropriate care plan according to their indvidal need Currently, within the Aneurin University Health Board, a Falls Response Service (FRS) has been operating since October 2016 and consists of paramedic and physiotherapist operating daily_This has been supported by the Welsh Government Integrated Care Fund. The FRS has had involvement with 1961 falls incidents received_via the 999 system from October 2016 up to 31s December 2018. 1475 people (75%) have remained at home following assessment andlor treatment the team, with the appropriate care being provided by community-based by 486 individuals (25%) required further treatment andlor treatment services_ 17% of individuals attended at hospital, and only required treatment within the Emergency Department The Trust is now engaging with UK Ambulance Services Project A; national improvement collaboration to share the Falls Framework and Falls Response model and from peer organisations on how we can continue to improve our to people who have fallen response In the interests of clarity; the Trust was not informed that Mrs Greenslade had and the coding given t0 her call by MPDS did notidentihaher asGreadylate had fallen and subsequently; therefore, the call was not considered for either a levelq or level 2 response under the Falls Framework: One of the issues that the Trustis now exploring is the value that Falls Assistants can add to our responses when patients are known to be on their Own, including engaging with careline companies to help information shared with the Trust improve the The uses the Resource Escalation Action Plan or REAP to provide services periods of increased demand or other NHS wide system pressures_ The REAP is UK agreed document used by all 13 NHS ambulance services, with some actions and locally agreed operational tactics . One of the aims of REAP is to ensure that we have a resource available for cardiac arrest or other high priority RED calls. In order to ensure this, the Trust reserves rapid response units for RED calls in REAP level 3 and 4. Whilst this means that some lower priority calls may wait longer for a response, it does ensure that we are always able to respond immediately to RED calls. would like to assure you that we have reviewed Bevan Only learn Trust during key

our REAP to prepare for winter 2018/19 and we now have a more dynamic to managing rapid response vehicles within each health board area, approach would whilst to respond to some of the specific matters of concern that you highlighted in your correspondence of 21 December 2018. 1_ The initial call was categorised as Green 3 without any contact made with Mrs Greenslade or her family and without clinical assessment This is consistent with processes used across Wales and the United Kingdom; in that all 999 calls are initially assessed based on the information provided to the call handler by the caller: Increasingly, and in cases where an ambulance response may not be appropriate, a clinician based in one of our CCC will make direct contact with the patient; where possible, to clinically assess the patients condition and provide advice over the phone (where this is appropriate)
2. After to make contact; no consideration was given to either upgrading the call category or to contacting Police to ask them to out a welfare check: Whilstwe have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with patient or caller at scene, we are of the view that it would not be appropriate to request police attendance tocundertake welfare checks for 999 calls to the ambulance service; a8 police officers are not suitably trained to make a clinical assessment: However; we are working collaboratively with our Police Force colleagues to develop Memorandum of Understanding regarding this issue 3_ Demand for ambulances was high compounded by excessive at hospitals_ Unfortunately, this was the case and often has & material impact on our ability to respond in a timely and reasonable way to calls that are not immediately life threatening: As set out in the accompanying action plan; we are shortly te commence an all Wales demand and capacity review to establish exactly what operational capacity is required to ensure we respond in the majority of cases within set waiting time and quality standards. This work will also assess current demand for services and what we can expect to see in the next five years. Arapid response vehicle had been based only eight minutes away from Mrs Greenslade's home since at least 0630 hrs and had not responded to any calls as it was ring-fenced for red and amber 1 calls: Rapid Response Vehicles are assigned to ensure that we can respond quickly as we can to immediately life threatening situations and life threatened patients_
5. The delay in medical intervention must have played a significant role in Mrs Greenslade's death do accept that the delay in responding to Mrs Greenslade was excessive and fell well short of that which we set out to provide like, writing; being failing carry delays

As the Trust has not received a concern or claim in relation in medical intervention to any impact the may have had in Mrs Greenslade's death; we are unable to comment on this element of your Report as an specific matter has not been undertaken. investigation into this That being said, the will now undertake & concerns investigation to address whether the deley did have impact The investigation will be undertaken under the National any (Concerns, Complaints and Redress Health Service Arrangements) (Wales) Regulations 2011 . Unfortunately, the Trust does not hold the details of Mrs Greenslade's kin or representative and would welcome next of to an opportunity to meet with the family, ensure that we can investigate fully: would like to reassure you that the Welsh Ambulance Aneurin Bevan University Health Board Services NHS and forward continue to work in collaboration to drive the improvements We continue to strengthen out of hospital alternative pathways to improve efficiency and effectiveness of care for our patients best use of our resources_ and make that we have been able to assure you that we remain focused to services together; and that actions taken to date have had improve our of the areas identified within an impact in relation to all this Regulation 28 Report: would like to extend the offer to meet with you to discuss and to provide with our response in more detail you assurance of our commitment to the continuous of our service provision. would also like to extend this improvement of the late Mrs Greenslade invite to meet with the family and to offer our sincere condolences at this very sad