Dear Ms Robertson

Re: Regulation 28 Prevention of Future Deaths report – Angela Frances Darlow (deceased) Thank you for your letter and the Regulation 28 Prevention of Future Deaths report of 5 February following the conclusion of the inquest into the death of Angela Frances Darlow. Please pass on my condolences to Ms Darlow’s family.

I take incidents of delays to NHS care and incidents where care does not meet our high expectations of the NHS extremely seriously. A 23-hour wait for an ambulance following a stroke is clearly not acceptable and is indicative of serious issues in the wider health and care system.

Your report rightly outlines concerns about the levels of demand faced by the Welsh Ambulance Services University NHS Trust (WAST) when Ms Darlow experienced a stroke as well as issues related to ambulance patient handover delays, patient flow, and social care provision for people in North Wales who are served by Betsi Cadwaladr University Health Board and the six local authorities responsible for health and social care services.

Ms Darlow was conveyed to the Countess of Chester Hospital, which provides NHS services to people in Wales who live close to the boarder with England. Betsi Cadwaladr University Health Board commissions the service.

Thank you for providing this Regulation 28 report – this is an opportunity for the health board, WAST, their partners and the Welsh Government to learn from what went wrong in Ms Darlow’s case and to put in place changes to address these failings.

Welsh Ministers set the strategic direction for health and care services and hold NHS organisations to account. Welsh Ministers are not responsible for the delivery of health or social care 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. I hold the chairs of all NHS organisations to account for oversight of the delivery of the strategic objectives through regular meetings. Welsh Government officials maintain oversight of the delivery of services via Joint Executive Team meetings held biannually and through regular integrated quality planning and delivery meetings where progress against key performance targets is scrutinised and assurance on the quality and safety of services is sought. Managing 999 ambulance demand In July 2025, a new emergency ambulance performance framework was introduced in Wales, supporting a move away from time-based targets towards a more clinically driven, outcome-focused approach, with an emphasis on responding quickly to people with time-sensitive conditions.

Two new categories of call were initially introduced in July – a new purple category for people suffering a suspected cardiac and respiratory arrest and the red category for people at high risk of cardiac and respiratory arrest, including where this is a result of injury or illness.

As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time.

The next phase of the framework was introduced in December, following a clinical review of the amber and green categories of call. A new orange – time-sensitive response category was introduced. This was designed to ensure people with conditions such as suspected stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact centres to receive a faster, more appropriate ambulance response, and rapid transport to specialist care.

The new framework also increases opportunities to better understand patient outcomes and experience by broadening measurement beyond initial response times to include more clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer insight into the timeliness and quality of care delivered to patients with serious and time-sensitive conditions, including stroke, to drive quality improvement.

The changes are being tested for 12 months and will be thoroughly evaluated. Improving ambulance patient handover performance As set out in my response to you in July 2025 to a previous Regulation 28 report, all health boards are expected to deliver the Ambulance Patient Handover Guidance. This was updated in January 2026 and issued to health boards for immediate delivery.

This reinforces that ambulance patient handover is a whole system responsibility, requiring co-ordinated action across all parts of the NHS and aligned to existing escalation arrangements. It also expects a more consistent approach to monitoring, assurance, and accountability, enabling system leaders to identify and address the underlying causes of handover delays rather than managing the symptoms alone. Delivery of the guidance is one of five priorities – called enabling actions – for urgent and emergency care in the NHS Planning Framework 2025-26 and will be maintained as a priority for 2026-27. It is also a feature of every health board chair’s objectives as a marker of performance. I set up a clinically-led National Handover-45 Taskforce last year to support delivery of a recommendation made by the Ministerial Advisory Group on NHS Performance and Productivity to eliminate ambulance patient handover delays of more than 45 minutes. The taskforce has brought together senior clinical, operational and system leaders from across NHS Wales and has overseen focused improvement activity, shared good practice, and provided national clinical leadership on safe and timely handover. Its work has helped to strengthen understanding about why handover delays happen, reinforced the importance of whole-system flow, and supported measurable improvements in handover performance across a majority of hospital sites in Wales. In February 2026, across all emergency departments in Wales there were 21% fewer ambulance hours lost as a result of ambulance patient handover delays and 19% fewer delays in excess of one hour compared to February 2025. However, despite some gradual improvement in the Betsi Cadwaladr University Health Board area over recent months, the pace of improvement is not where it needs to be and the three district general hospitals have the worst performance in Wales. I am concerned about the ongoing level of ambulance patient handover delays in North Wales and the impact this has on ambulance availability in the community. I have been very clear with the health board about my expectation for sustained improvement in this area and in improving patient flow through the hospitals and the wider health and care system in North Wales.

Patient flow in acute hospitals As highlighted in your report, some of the issues the NHS is experiencing at the moment are because people are not being discharged home quickly when they ready to leave hospital.

The NHS and local authorities took part in two winter sprint fortnights in December 2025 and January-February 2026 – these were periods when all organisations focused on a set of actions to improve flow through the health and care system, with the intention of embedding the learning into business as usual working. During the sprint periods, more people were discharged earlier in the day, and there was better use of discharge transport capacity and fewer ambulance patient handover delays.

Our Pathways of Care Delays reporting framework provides all health and social care organisations with comprehensive monthly oversight of the key reasons for delays and recurring themes. Regions use this, together with wider population needs data, to identify local drivers of delay to help shape community service provision.

The most recent data shows some monthly reductions in both the total number of delayed discharges and days delayed at an all-Wales level. In North Wales, there has been some fluctuation in discharge delay figures over the winter period which demonstrates there is

room to make further improvements. The Welsh Government is working with the regional partnership board to identify actions which can be taken to tackle local challenges, such as the trusted assessor models and Discharge to Recover then Assess (D2RA) pathways.

To further support discharge and patient flow, we allocated £30m to local authorities via a new Pathways of Care Transformation Grant in 2025-26. Local authorities are using this to support timely discharge and prevent avoidable hospital admissions by strengthening community-based social care.

There is some indication of improved capacity in domiciliary care in North Wales, with an increase in provision and fewer people waiting for support, although demand pressures are higher than in many other parts of Wales. Reablement delivery is broadly in line with other areas, although there is variation in reablement service models across local authorities. Additional support for Betsi Cadwaladr University Health Board Betsi Cadwaladr University Health Board is at the highest level of escalation – special measures – because we have serious concerns about how the health board is run; about the quality and safety of service; about the performance of services and about timely access to care.

The Welsh Government is providing additional financial and expert support to the health board to help it make the necessary improvements to services. I recently announced a team of experts who will work alongside the executive team to focus on:
• Reducing ambulance handover delays and improving flow
• Reducing waiting times for planned treatment and diagnostic tests
• Improving waiting times for cancer diagnosis and treatment
• Further strengthening governance, assurance, and leadership capability.

The health board recognises the serious and multifactorial pressures facing the urgent and emergency care system in North Wales. The system is complex and requires a whole- system approach to address increasing demands and to improve the accessibility, experience and outcomes for the communities it serves. Many of these challenges are not unique to North Wales and while the health board has made some improvements, significant transformation of services is necessary to deliver sustainable improvement.

Thank you for this Regulation 28 report.