Dear Mr Layton Re: Regulation 28 Report in relation to the death of Michael Davies am writing in response t0 your Rogulaticn 28 Roport issued €n 25 April 2019 follcwing the sad death of the late Mr Michael Davies_ In the report you raised your concerns in relation to three matters_ Followirig receipt of the Regulation 28 would sincerely appreciate the opportunity to discuss these with you as the Trust does not propose at this time_ to take any action in relation t0 the three matters you have raised_ The reasons for which will explain below: Matters of concern noted in the Regulation 28 report: During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed an Amber categorisation whenever the patient is conscious and breathing: The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response_ The effect of removing chest pains and related conditions from Category Red is the response time, previously minutes, now up hours and often palients are advised t0 make their Own way to hospital: This puts patients' lives at risk and in this inquest may have contributed to the death of Davies. Caiein cCha Wattin Wzoo rd Puf Werhrooan Cnict ~Xecu ve Jascn Kilens Mac 5 YMolinetc belc cicesakd MJrojaenh Y GCforonilt Sagocc {ca Trust weicomuentasottrance velsh Eraudt and

My letter dated the 18 March 2019 contains relevant information regarding the actions that the Trust is currently taking to ensure that it has sufficient resources to respond appropriately to each patient and to reduce patient waiting times more generally: As yOu explored during the inquest, each ambulance service has response model that supports the categorisation given to each call (irrespective of which prioritisation system is used) . That response model and the decisions made will reflect the demographics of the population and the geography being served by that individual ambulance service. notice that you have relied on evidence informing your view and subsequently the noted concerns that England (or parts thereof) have some chest pains as red category of call, requiring an minule response_ would respectfully draw to your attention to the fact that England operates national system of respurise prioritisation followlng the introduction the Ambulance Response Program (ARP): More information regarding the Ambulance Response Program , which reflects the Clinical Response Model used here in Wales, can be found at https wwwengland nhs uklurgent-emergency-carelarpl: It is therefore correct say that England operates universal; L.e national system of response prioritisation and that, in line with the system operated here in Wales only when a chest pain call is identified as being unconscious and not breathing does it attract red response category. With regard t0 point 2 of the Regulation 28 Report, would Iike to take the opportunity to explain that Amber calls do not attract planned response of up to four hours within the clinical response model, nor is it correct t0 say that patients are cften advised t0 make their own way tO hospital: It would be right to say however that around 0% of all patients who dial 999 are offered advice by a senior clinician over the telephone which may include self-care advice or instructions to make their own way to healthcare facility: This is only the case where it is clinically appropriate and safe to do s0 and supports the provision of sufficient emergency ambulance capacity being available to respond to those patients who do genuinely require such_ During the inquest, specifically the evidence provided by you were informed that since February 2018 changes have been made '0 tne scripts used by the call takers within our clinical contact centres did advise that she was unable t0 answer your questions in relation to what callers were now told as she did not have that information available to her. When pressed she did advise that a worst case scenario would be callers being informed that an ambulance may take up t0 four hours to amive_ However for clarity this advice was in relation to calls that were categorised as green or Amber 2 only. attach for your reference the Demand Management Plan and the associated scripts that are used by staff at different stages of the escalation or pressure within the plan. As you will see from these documents when the Demand Management Plan stage and 2 are in use there is no scripted delay advice in relation to Amber calls_ When the Trust is operating in Demand Management Plan stage 3 we will advise callers , whose call has been categorised as an Amber 1 that the delay may over an hour; and should the Trust move into Demand Management Plan stage the advice given to callers in relation to Amber calls is that an ambularice may be delayed for over two hours would however be right to offer balance in this respect in that whilst over 50% of patients who attracted response category of Amber during 2018/19 received resporise within 17 minutes there are clearly number of patients who do regrettably wait longer that we would like_ raising

During the winter months from December 2018 through to February 2019 there was marked decrease in the length of time the Trust spent at the highest level of escalation within the plan; December 2018 17% compared with December 2017 - 32%. January 2019 - 36% compared with January 2018 48% February 2019 _ 21% compared with February 2018 _ 48% Whilst che Trust in ils letter tol and in the oral evidence provided at the inquest, acknowledges that there was delay in an ambulance being allocated to Mr Michaei Davies on February 2018 this was an unavoidable delay: This is because at 11.25 hours when the call was received_ and allocated the Amber categorisation there were no vehicles available to the Trust t0 send to Mr Michael Davies; This resulted in the open microphone call being made to all ambulances in the vicinity at 11.31 hours_ As you will appreciate _ whilst the Trust strives t0 allocate vehicle immediately to Amber calls_ this is not always possible especially during periods when demand outstrips supply. In closing; am of the view that the principle issue for us here is not one of categorisation as it is right to have system of priority that assigns more rapidly to clinical severity but ensuring sufficient resource availability to meet demand and response within reasonable time from to all our patients_ hope that have been able to assure you that we remain focused t0 provide the best possible service for the people of Wales would like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you require regarding our commitment to continuous improvement: