Dear Mr Gittins Re: Mrs Shirley Ann Hughes I write in response to the Prevention of Future Deaths Report issued to this Trust on 28 October 2025, following the inquest in relation to Mrs Shirley Hughes. The matters of concern that you have asked the Trust to consider are: “For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however on every occasion when evidence is presented at inquests, I am reminded that calls are prioritised using the Medical Priority Dispatch System (MPDS) by which a code is generated and that this is then matched to a response priority to provide an indication as to the most appropriate resource to respond.

At the inquest of Mrs Hughes, I was advised that MPDS was introduced in 2015 and at that time it was envisaged that an amber 1 priority call would be responded to in 20 minutes, however it was clearly the case that the multifactorial issues which prevail today were not envisaged at that time and that as a consequence this raises questions as to whether the MPDS system remains fit for purposes. As a result of this evidence, I am concerned that lives are being put at risk.”

I would like to start by explaining that the MPDS system has been used by the Trust since the 1990’s and is the system by which the Trust prioritizes the calls it receives.

To the Trust’s knowledge, MPDS and NHS Pathways are the only available products, worldwide. NHS Pathways is only used in England. In comparison to MPDS, NHS Pathways has a very small group of users, and the number of patients triaged using this tool versus MPDS is very small.

In the absence of NHS Pathways or MPDS, it would require significant inhouse development to produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also deployed Emergency Communication Nurse System (ECNS) and Call Priority Streaming System (CPSS), both of which support our strategic direction. These are from the same provider as MPDS. There are a number of advantages presenting themselves, which is the potential synergies between MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 and 111 contacts).

Your reference to 2015, we believe refers to the trial of a new Clinical Response Model (CRM) which commenced in October 2015. The CRM guides the way in which the Trust utilises its resources. An initial trial was undertaken for 12 months and extended by a further 6 months. In February 2017, the CRM was approved by Welsh Government and has remained in place since that time. During the trial of the Trust did have in place an internal only target to attend Amber 1 calls in 20 minutes. For clarity this was purely an internal, non-official target, which ceased when the CRM was fully adopted in 2017. Since 15 October 2015, the Trust has had only one official time based target, and that is in relation to an 8 minute response to 65% of ‘Red’ cases. You may now be aware that on 26 November 2024, the Cabinet Secretary for Health and Social Care, , announced the establishment of a task and finish group to review our current “red” target and associated metrics. This comes after the Senedd’s Health and Social Care Committee published a series of recommendations in August following its general scrutiny of the Welsh Ambulance Services University NHS Trust in May 2024. The scrutiny report has been included as an appendix to this letter (Appendix 1). The emergency ambulance response measures task and finish group will comprise of senior civil servants and policy leads, representatives of the Joint Commissioning Committee (JCC), clinicians and members of our leadership team. This group will work at pace and is due to report to the Cabinet Secretary early next year with a view to updating Committee, and Senedd members, by the end of February 2025. The Trust does not propose to take any additional, or new, actions specifically in relation to this Preventing Future Deaths report because of existing plans already being enacted. Whilst we recognise that this may appear insensitive given the loss Mrs Hughes’ family have experienced and in light of the risks you raise with us, we hope to provide assurance that the Trust already recognised the risks and pressures within Urgent and Emergency care pathways and is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from its commissioners through it commissioning body, the JCC, Welsh Government, the wider NHS and Local Government to ensure appropriate clinical risk management across the urgent and emergency care pathway to release resources with the Trust.

In addition to the Governmental task and finish group referenced above, and aligned to our 2024- 27 IMTP, the Trust has commenced work to evolve its Clinical Services Model. We have provided an overview of our current position and planned incremental changes under the headings below. Current Situation ▪ We fully understand and acknowledge the long standing and entrenched problems facing health and social care services. ▪ The challenges facing the system are complex, and not easily solved by a single organisation unilaterally. ▪ This is no consolation for families who have been caught up in the challenges of the current system. ▪ It is our view that the traditional ambulance model of care needs updating to reflect both increasing clinical skills of staff and increasing opportunities presented by technology. We need to think differently. ▪ As a result, we recognise that there is more we need to do ourselves to improve patient care and experience for patients calling 999. ▪ We are looking to potentially do things differently in the future and are working closely with commissioners on the art of the possible in terms of ‘evolving’ our clinical services model. What are we looking to achieve? ▪ Protect our ambulance resources for patients most in need of an ambulance response ▪ We only want to convey patients to hospital whose needs cannot be met by the Trust or in another part of the system. ▪ Enhance our ability to resolve more care through the Trust led interventions without needing an emergency ambulance response. Including: o Enhancing our ability to manage more patients’ needs remotely following a remote clinical assessment. o Patients’ needs are met in their own home following a face to face clinical assessment through an enhanced community response services (e.g., Advanced Paramedic Practitioners, Falls Response, Mental Health Vehicle). o Improve access to signpost / refer patients whose needs are best met by another service. Core foundations of the model ▪ The core foundations of the model are set out below:

o Clinically led – there will be increased clinical input, earlier in the call cycle and throughout the patient journey. Clinicians will be actively involved in decision-making on the right pathway for each patient as part of a care planning process. o Connectivity – systems, processes and people across the Trust will be increasingly connected so that patients get the right care in the right place, irrespective of their

point of access (e.g., Digital access, NHS 111, 999 or the Ambulance Care service for non-emergency patient transport). o Care Planning: We will adopt a personalised care planning approach for all patients, providing robust clinical oversight of the patient throughout their episode of care until their needs are resolved and case closed with the ambulance service. o Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. o Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care pathways for the Trust clinicians to safely and appropriately refer patients to meet their care needs. What are our current priorities? ▪ We are in close collaboration with Welsh Government, our commissioners and health boards to focus on opportunities for improvement, including improving access to local pathways of care to provide more options to safely avoid patients being conveyed to hospital. ▪ As part of our plans for winter we are embedding new clinical roles in our control rooms to proactively triage 999 calls earlier in the call cycle. By using clinical expertise, it enables more effective clinical decisions regarding the best care to meet the patient’s needs. What will be the impact? ▪ We will be monitoring the impact of these developments and working with commissioners and partners to work through opportunities for further development and collaboration. When will we see changes? ▪ Our aim in the short term is to make the service ‘safer’ over this winter. ▪ Implementation of an evolved model of care (pending commissioner endorsement) will be delivered in a phased approach, and the programme is likely to run for period of circa 2/3 years. ▪ We expect to see incremental improvement as different interventions are implemented and embedded throughout the programme timescales. ▪ We recognise that no single intervention can fix the problem. ▪ The level of improvement is dependent upon how well the wider system is functioning. Ongoing Engagement ▪ We continue to work with partners across the system, commissioners and Welsh Government on collective support and action so that we can make further improvement. ▪ We will be undertaking more targeted engagement with key stakeholders, including coronial services, to support our emerging plans in the near future.

We hope that this information supports our position that we are doing everything within our sphere of control and influence to deliver more timely, safer care however we are acutely aware of the limitations of our actions within the wider health and care landscape of extreme pressures across Urgent and Emergency Care systems. The number of hours' worth of Trust emergency ambulance production lost per month due to long waits at emergency departments is consistently reaching the 25,000 to 30,000 hours mark. This equates to approximately 20 per cent to 25 per cent of our entire fleet capacity every month as a result of the pressure right across the urgent and emergency care system. This issue remains the highest influencing factor on our ability to provide timely responses, far above and beyond the incremental improvement measures being taken internally by the Trust. To this end, Welsh Government released a revised Welsh Health Circular (WHC-2024-041) on ‘Ambulance patient handover guidance’ shortly following the conclusion of Mrs. Hughes’ inquest. This document replaces the existing 2016 WHC on the same subject and reinforces the expectation that “robust arrangements are in place to ensure rapid handover, within 15 minutes of arrival”. (Appendices 3 and 4) While the Trust fully supports the need to issue a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, we do not believe that we are the primary authority with the “power to take such action”. Therefore, I respectfully request your consideration as to any further actions you feel the Trust could take, over and above those that we have already shared with you. Equally, I would genuinely welcome any suggestion you may have regarding actions we might take or seek to take with our partners. We continue to work tirelessly at internal mechanisms to reconfigure and improve resource allocation, regularly reporting to our Trust Board on the steps taken to mitigate patient harm. However, we recognise that we are not an organisation with a full solution in the broader context. I am therefore extending an offer to meet with you to discuss our response in more detail, and to provide you with any further assurances you may require regarding our commitment to continual improvement to proactively prevent harm and future deaths. I would like to again offer my sincere condolences to Mrs. Hughes’ family on their sad loss. Any reference to the systemic nature of the root causes for delays are in no way intended to be dismissive of the unacceptable and tragic loss of life and the grief her family are experiencing. If you wish to take up the offer of a meeting with myself or a member of my Executive team, please contact , Legal Services Manager, who will be happy to arrange this. Her contact email is and her telephone number is: .