Dear Mr Phillips

Inquest into the death of Andres Roberts

I write in response to the Regulation 28 Report that you issued on 23 September 2020, following the sad death of Mr Andres Roberts. In the report you raised your concerns in relation to three matters, namely:

Matters of concern noted in the Regulation 28 report:

1. The appropriateness of the grading of stroke patients falling in the amber category;

2. Whether a specific time target should be set;

3. Whether additional resources should be made available to the Trust to meet these targets.

2 Following receipt of the Regulation 28, and consideration of the facts within, I 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 to the three matters you have raised. The reasons for which I will explain below.

Each ambulance service has a 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. In 2015 the Welsh Ambulance Services NHS Trust introduced its current Clinical Response Model (the Model), which removed timed targets for all but those patients with immediately life-threatening illnesses or injuries. The Model underwent a trial period before being approved by the Welsh Government and fully implemented by the Trust.

The Trust’s Model is in line with England. In England ambulance services operate a national system of response prioritisation following the introduction of 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

It is therefore correct to say that England operates a universal, i.e. national system of response prioritisation and that, in line with the system operated here in Wales, only when stroke symptoms identify that a patient is unconscious and not breathing does it attract a red response category.

Stroke calls in the English response model are prioritised as either Category 2 (second highest priority, of five) or Category 3 (third highest priority). These categories are aligned to Amber-1 and Amber-2 priorities in Wales (which also represent the second and third highest priorities, respectively). The primary determinant of whether a call for a patient with suspected stroke is in the Amber-1 or amber-2 priority, is the time onset of symptoms, as more recent onset of symptoms are a higher priority, if the patient is still within the window of opportunity for thrombolysis.

The appropriateness of the priority given to each category of call is reviewed and changes are considered by the Trust’s Clinical Priority Assessment Software (CPAS) Group. In all cases the group will consider the impact any change would have on the volume of Red calls received, the effect of increasing the Red calls and the impact on other codes. The CPAS group also sets an “ideal” response for each type of call, in an attempt to maximise efficient use of resources by avoiding “double dispatch” on calls. If a patient is suffering a stroke, the dispatch of a paramedic in a car (rapid response vehicle) does not aid the patient directly, as the key treatment (if stroke is suspected) is conveyance to hospital for brain scans and consideration for thrombolysis. Thus the paramedic in an RRV would only be able to confirm the likely diagnosis, and request a conveying ambulance to attend. The clinically important time is therefore not the time taken to respond to the 999 call, but the time taken from onset of symptoms until arrival at hospital.

I would respectfully like to advise you that not all patients displaying possible symptoms of a stroke are prioritised as an Amber call. Some patients will be prioritised as Red, some Amber and others Green, dependent on their symptoms. The Trust’s model aims to attend patients dependent on the severity of their symptoms, with the correct vehicle, as soon as possible.

It would however, be right to offer balance in this respect, in that whilst over 50% of patients who attracted a response category of Amber 1 during 2019/20 received a response within 27 minutes there are clearly a number of patients who do regrettably wait longer that we would like.

3

In closing, I am of the view that the principle issue for us here is not one of categorisation as it is right to have a system of priority that assigns more rapidly to clinical severity.

In relation to whether additional resources should be made available to the Trust to meet these targets, the Trust has undertaken a Demand and Capacity review, which has identified the need for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority of these additional staff will be introduced over the next 4 years to increase the relief capacity within the current rosters, allowing for increased ambulance provision to meet demand.

At the time of this specific incident there were significant delays in transferring the care of patients from ambulance to hospital staff. Specifically, there were 9 emergency ambulances awaiting to handover their care to hospital staff, with the longest wait in excess of 8hours.

When vehicles are delayed at hospital this effects our ability to respond to patient’s in the community and causes significant pressures upon our services. Accordingly the Trust has developed a Demand Management Plan to manage actions across our services at times of escalated pressure.

Another action that is being taken forward is to offer support at challenging times include the Operational Delivery Unit (ODU). The ODU is a pilot model designed to provide 24/7 leadership in support of the Welsh Unscheduled Care system, and as a central hub to co-ordinate flow and mitigate potential risks to patient care. To date it delivers 16 hours a day operating between 08:00-midnight, which was reduced in August 2020 to 12 hours a day.

The ODU has a dual role in providing an independent leadership role to facilitate collaboration with Health Board partners in parallel to being aligned to the Welsh Ambulance Operations directorate supporting Emergency Medical Services operations.

It has been designed to monitor the daily situation and consider actions that may impact upon the delivery of care, utilising principles that seek to pre-empt, mitigate, and react to any issues that may arise. The National Delivery Manager is the senior on duty decision maker out of hours in support of on call teams and helps reduce the need to use on call staff that have been on duty in the day.

It has developed a close working relationship with site teams that are responsible for the flow of patients through the hospital which enables early dialogue when delays occur. The ODU will provide the sites with details of calls polling (waiting) in the community as an early predictive indicator of demand that is potentially going to need an Emergency Department admission. When delays start to occur the ODU will contact the site to establish a time line for transferring patients and will discuss any divert options if appropriate.

If there is a high volume of calls in any particular area the ODU will liaise with the Clinical Support Desk shift lead to discuss targeting proactive clinical support to help discuss alternative options for patients other than Emergency Departments.

4 It works closely with bed management teams to encourage early discharge transport arrangements so that delays for patients to be discharged home are minimised and Non- Emergency Patient Transport Service ambulances are appropriately utilised.

I can provide you with assurance that the Trust continues to work with all Health Boards across Wales to address the problems associated with our ambulances (be that Emergency, Urgent Care or Rapid Response Vehicles) being delayed at hospital. I personally wrote to the Chief Executive Officers of the Health Boards across Wales in August of this year to share my concerns regarding the pressures on our services when our resources are delayed at hospitals.

The Trust has various ongoing actions to help reduce the pressure on busy hospital departments, which will improve patient flow within the wider NHS system and maximise the availability of our emergency ambulances for our most critical patients.

• We have expanded our clinicians on the clinical desk in our 999 control room to support timely clinical assessment and to ensure we are sending the appropriate resource to the individual patient.
• We are working in collaboration with the Health Board to develop out of hospital pathways to safely reduce the need to convey patients to hospital.
• We also support the discharge and transfer of patients out of hours in order to release beds in hospitals, which in turn supports the improvement of patient flow in the emergency departments.
• Where safe to do so, the Trust aims to support people in the community and to reduce the number of unnecessary admissions to Emergency Departments.
• We continue to recruit and train Advanced Paramedic Practitioners who have a higher skill level and are trained to treat patients at their own homes, where possible.

I hope that I have been able to assure you that we remain focused to provide the best possible service for the people of Wales.

I 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.

Dear Mr Phillips,

Regulation 28 Report to Prevent Future Deaths – Andres Roberts

Thank you for your letter enclosing the Regulation 28 report following your investigation into the death of Andres Roberts at Morriston Hospital in Swansea in August 2019. I am responding on behalf of Vaughan Gething, Minister for Health and Social Services.

Please accept my apologies for the delay in responding.

The Welsh Government and the Welsh Ambulance Services Trust (WAST) recognise the importance of providing a safe and timely ambulance response to suspected stroke patients, as a key part of their patient journey. The Trust aims to respond to patients with new onset stroke as quickly as possible by dispatching a suitable emergency ambulance vehicle under blue light driving conditions, which is capable of transporting the patient immediately to a specialist stroke team to begin the treatment they require. The Trust has also put in place strong clinical guidance that must be followed for all suspected stroke patients, which ensures that actual and potential stroke patients are transferred to the appropriate settings within the clinically agreed guidelines.

As part of the introduction of the clinical response model in Wales in October 2015, time-based targets were removed for all but the highest priority immediately life-threatening or ‘Red’ calls. This decision was made on the basis of clinical evidence that a higher proportion of patients in most need of an immediate intervention would receive a faster response to optimise their outcomes.

An independent evaluation of the model1, published in January 2017, found clear and universal acknowledgement, both from within the ambulance service and external partners, that moving to a model based on clinical prioritisation was the right thing to do and has helped to deliver a service that is more focussed on the quality of care patients receive as well as improving efficiency in the use of ambulance resources. There is also evidence that the previous practice of applying a time-based target for all emergency ambulance calls, irrespective of clinical

1 https://easc.nhs.wales/publications/pacec/pacec-documents/pacec-wast-clinical-model-evaluation/

priority, was driving perverse behaviours and resulting in poor and inefficient clinical interventions for patients.

The Amber Review2, published in October 2018, questioned the value of a response time as a measure of the impact and quality of ambulance service care to non-immediately life threatening calls. While this does not mean that time is not important, it highlights that the initial ambulance response is part of a patient journey and that ensuring patients receive the most appropriate response and timely access to the right specialist treatment is often more important to ensure a good patient outcome, particularly for conditions such as acute myocardial infraction and stroke.

The Review made nine recommendations and identified a number of areas where further work was required to gain an improved understanding of the challenges and opportunities to improve responses to calls in the ‘Amber’ category. While it did not make any specific conclusions or recommendations relating to ambulance response to stroke, the Emergency Ambulance Services Committee (EASC) is committed to developing the Ambulance Quality Indicators to include a broader range of meaningful measures for strokes and other time dependent conditions, while protecting the integrity of the clinical response model.

Discussions are ongoing between EASC and WAST, in consultation with Community Health Councils, the Stroke Association and its patients groups, and NHS Wales partners, to consider a broader range of measures that give greater context to ambulance response times to people who have a stroke, for publication in the New Year. We hope that delivery of a new measure can be a major step forward in understanding the current care being delivered for stroke patients in Wales and to allow us to focus on improving the right area of the pathway.

We also continue to work with WAST and Health Boards to implement the recommendations of the NHS Wales Delivery Unit All-Wales Thrombolysis Review, published last year. The review identified a number of national cross-cutting themes across Wales that would benefit from an all-Wales approach and made a number of personalised recommendations for WAST and Health Boards to address the variation in the number of people who receive thrombolysis in Wales. Whilst Covid-19 and the retirement of the national clinical lead for stroke has slightly delayed progress, the new clinical lead for stroke in Wales, Dr is committed to ensuring that all outstanding review recommendations are implemented as soon as possible.

I note your concerns regarding resources available to enable WAST to respond to calls in a timely manner. The Trust is currently implementing the recommendations of an independent capacity and demand review, which will see 136 FTE staff recruited in 2020/21, significantly increasing the number of frontline staff available across the service to respond to incidents. This should support an improvement in responsiveness, although the wider health and care system also has a role to play in enabling improved patient flow through the hospital system and out into the community. This should reduce ambulance patient handover delays and unlock more capacity to respond quickly. A range of actions are also underway to better manage patient demand in the community to help prevent avoidable transport of patients to hospital.

We continue to work with NHS Wales and social care partners to support improvement across health and social care services, and through the COVID-19 NHS Wales Operating Frameworks for quarter 2 and quarter 3 / quarter 4, we have outlined six goals for urgent and emergency care services over 2020/21 and beyond:

2 https://easc.nhs.wales/publications/amber-review/amber-review-documents/amber-review-english/

1. Co-ordination, planning and support for high risk groups - Planning and support to help high risk or vulnerable people and their carers to remain independent at home, preventing the need for urgent care
2. Signposting, information and assistance for all - Information, advice or assistance to signpost people who want - or need - urgent support or treatment to the right place, first time.
3. Preventing admission of high risk groups - Community alternatives to attendance at an Emergency Department and/or admission to acute hospital for people who need urgent care but would benefit from staying at, or as close as possible, to home.
4. Rapid response in crisis - The fastest and best response at times of crisis for people who are in imminent danger of loss of life; are seriously ill or injured; or in mental health crisis.
5. Great hospital care - Optimal hospital based care for people who need short term, or ongoing, assessment/treatment for as long as it adds benefit.
6. Home first when ready - A home from hospital when ready approach, with proactive support to reduce chance of readmission Through delivery of this approach, key local and national interventions, and development of underpinning operational plans, we will work with national, regional and local partners to change the ways that patients access urgent and emergency care services to ensure they are able to receive advice, assessment and treatment from the right place / setting / clinician, first time.

We have also made £30m additional funding available to enable transformation of urgent and emergency care services and increase resilience over the remainder of 2020/21, including four priorities to optimise patient flow, experience, outcome and value when people access urgent and emergency care services:

 111/contact first models to enable patients with urgent care needs to be signposted to the right place, first time.  24/7 urgent primary care centre models of care to enable people to access care in their local community, preventing unnecessary attendances at ED  Ambulatory or same day emergency care (AEC/SDEC) to enable patients to safely bypass the ED and prevent unnecessary admission  Four discharge to recover then assess pathways (D2RA), to prevent unnecessary admission and enable a home first approach.

You may also wish to be aware that a Ministerial Ambulance Availability Taskforce has been established to focus on ambulance responsiveness and the need for wider whole-system improvements to reflect and respond to the changing environment in which ambulance services are delivered. This includes the changing picture of demand and performance for immediately life-threatening (Red) calls, ambulance patient handover delays and the wider health and social care landscape. The taskforce will have a key role to play in delivering a more effective ambulance response and while it was temporarily stood down to enable a focus on the response to Covid-19, but its work programme has been resumed and will be expedited, with a view to submitting its interim report to the Minister by the end of December 2020.

I hope this is helpful.