Dear Mr Hughes, I am writing in response to your letter and Regulation 28 Prevention of Future Deaths report on 13 June following the conclusion of the inquest into the death of Valerie Hill. Please pass on my condolences to Ms Hill’s family. Your report raises concerns about the impact of ambulance patient handover delays at Cwm Taf Morgannwg University Health Board, in particular, on patient outcomes and on ambulance responsiveness to 999 calls in the community. The Welsh Government expects the NHS to provide a high standard of care to everyone who seeks treatment. I am saddened when care falls below that standard, especially when it results in harm. I am grateful to you for providing this Regulation 28 report – this is an opportunity for the NHS and the Welsh Government to further learn from what went wrong in Ms Hill’s case and to work together to put in place changes to prevent more people experiencing the same issues and failings. I will set out the roles and responsibilities in relation to the health service and address your concerns. Governance: roles and responsibilities Welsh Ministers set the strategic expectations for health and care services and hold health bodies accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services. Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their respective areas within the national policy framework set by Welsh Ministers. The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 established the Welsh Ambulance Services University National Health Service Trust

(WAST). Article 3 delegates the function of managing the ambulance service to WAST. It is responsible for delivering emergency ambulance services, in line with the commissioning intentions set by the NHS Wales Joint Commissioning Committee (JCC). The JCC is a joint committee of health boards established to jointly exercise the functions of planning, securing, and commissioning of emergency ambulance services. The Welsh Government’s clear expectation is that when someone is conveyed to hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance. Our policy expectation, and the commissioning intent of the NHS JCC, is that WAST prioritises response to those in most need and aims to provide the right response, first time to optimise outcomes and experience. The Cabinet Secretary for Health and Social Care holds the chairs of health boards and WAST to account for oversight of the delivery of those expectations through regular meetings. Welsh Government officials maintain oversight of the delivery of services via Joint Executive Team meetings held biannually and through bimonthly integrated quality planning and delivery (IQPD) meetings where progress against key performance targets is scrutinised and assurance on the quality and safety of services is sought. Ambulance patient handover performance I remain concerned about the level of ambulance patient handover delays at emergency departments and the impact of these delays on people’s outcomes; on NHS staff morale and on the Welsh Ambulance Service’s ability to respond to people in the community. Until recent months, I have been disappointed with the slow progress in reducing ambulance patient handover delays. As your report notes, addressing this requires co-ordinated action across the entire health and social care system, with strong clinical leadership and executive-level commitment from health boards. The Cabinet Secretary for Health and Social Care has been clear with health boards about his expectation for improvement in the timeliness of ambulance patient handovers. All health boards are expected to deliver the Ambulance Patient Handover Guidance, which has been established as one of five priorities (‘enabling actions’) for urgent and emergency care in the NHS planning framework for 2025-26. It also features as part of the health board chairs’ objectives as a marker of performance. A review of health board compliance was commissioned in quarter four of 2024-25 and completed in March 2025 by NHS Performance and Improvement. A report containing learning and key themes for health boards to consider was shared by Welsh Government on 18 June 2025. A copy is attached at annex A. Welsh Government officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects from the report to support compliance with the handover guidance and work towards delivery of no delays in excess of 45 minutes by quarter three of 2025-26. Progress will be followed up by officials and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings with health boards.

The independent Getting it Right First Time (GIRFT) and Ministerial Advisory Group on NHS Performance and Productivity report also underscored the need for change. The Cabinet Secretary for Health and Social Care has announced a National Handover-45 Taskforce to support health boards and WAST to deliver system-wide improvements to improve ambulance handover. The taskforce will develop and support delivery of high-impact clinical pathways in the community; support the delivery of effective evidence-based emergency department processes and support the delivery of evidence-based processes to improve the flow of patients from emergency departments to wards and optimise discharge. It will play a key role in assessing and supporting the readiness of NHS Wales to deliver every ambulance patient handover within 15 minutes as far as possible, but always within 45 minutes. The taskforce will be led by:
• , executive director of nursing at Aneurin Bevan University Health Board.
• , executive director of allied health professions and health science at Hywel Dda University Health Board.
• , executive director of precision medicine and executive medical director at Cardiff and Vale University Health Board.
• , executive director of paramedicine, Welsh Ambulance Services University NHS Trust.
• , executive director of quality and nursing, Welsh Ambulance Services University NHS Trust. They will be supported by NHS Wales Performance and Improvement and the NHS Wales Joint Commissioning Committee. The taskforce will use the NHS Performance and Improvement review as a foundation and compile comprehensive evidence about effective strategies for improving ambulance patient handover. This will inform the development of an improvement programme and a readiness assessment. The taskforce will support health boards and WAST through a series of rapid improvement events over a 30, 60 and 90-day period. These will bring together senior clinical and operational leaders at a health board level with a focus on high-impact pathways, emergency department processes, improving patient flow and encouraging clinical ownership of actions. There have been some encouraging signs of improvement because of local strategies, the work of the Six Goals for Urgent and Emergency Care programme, and the Wales-wide focus on reduced delayed hospital discharges. These approaches will be shared with all health boards and the taskforce will also draw on other successful cultures, processes and models from across the UK. In June 2025, across all emergency departments in Wales there were 31% fewer ambulance hours lost caused by ambulance patient handover delays and 24% fewer delays in excess of one hour when compared to June 2024. In the Cwm Taf Morgannwg University Health Board area, there were 33% fewer ambulance hours lost, and 69% fewer patients delayed more than an hour when compared to June 2024. The 15-minute performance was 47% and we expect to see this improve.

Planning for winter 2025-26 As the winter period traditionally presents greater challenges for emergency care services, the process of learning lessons from last winter and developing plans for winter 2025-26 started at the earliest possible stage on 31 March 2025. The Cabinet Secretary for Health and Social Care chaired a Winter Summit meeting with NHS chief executives, directors of social services and the Association of Directors of Social Services (ADSS) Cymru. The outputs from the summit have been co-ordinated by Welsh Government officials and expectations of health and social care partners, with guidance and good practice was issued to NHS organisations and local authorities on 14 July 2025. Escalation and Intervention Escalation is used to hold health boards to account for delivering the services the people of Wales require. It enables us to offer appropriate support so that they get the help they need to make the desired improvements. Our approach to oversight, escalation and intervention is set out in the NHS Oversight, Assurance, Escalation and Intervention Framework. The framework sets out six escalation domains against which all health organisations are assessed. In line with the processes described within the document, Welsh Government officials undertake an assessment of each health organisation against each of the domains at least twice a year. These assessments draw in a variety of evidence and are used in conjunction with evidence and intelligence from statutory organisations by Welsh Government officials to inform the recommendations made to the Cabinet Secretary, on the escalation levels of NHS organisations in Wales. The latest escalation levels for each organisation were published in July and are available at NHS Wales escalation and intervention arrangements | GOV.WALES. All health boards in Wales, are in escalation for urgent and emergency care, which includes ambulance handovers. Cwm Taf Morgannwg University Health Board is in level four escalation (the second highest level) for urgent and emergency care. Decisions about escalation levels are taken at least twice a year, and more frequently if serious concerns persist. This process involves the analysis of data, outcomes, and patient experiences amongst others. Views are taken from statutory bodies and others. Welsh Government officials use this collective information to assess escalation levels and make recommendations to the Cabinet Secretary for Health and Social Care. When considering whether an increase in escalation level or special measures is necessary a clear rationale is required including analysis of what improvements and support can be offered via escalation or intervention before that recommendation can be made. All organisations in escalation have an agreed escalation framework, this sets out very clearly the criteria for de-escalation to the next level. The Welsh Government will work with the health board to agree the support required depending on the areas of concern and ensure that this is implemented and progress against the escalation frameworks is reviewed monthly in formal meetings. Achievement of this criteria will result in de-escalation, while failure to achieve will increase the level and nature of interventions.