Dear Mr Hughes Re: Inquest relating to Mr Paul Mclean write In response 0 the Regulation 28 report that you issued t0 this Trust, dated the 22 October 2019, following the sad death of the lale Mr Paul Mclean who sadly died on 9 October 2018_ In the Regulation 28 report you raised your concerns in relation t0 four matters The adequacylaccuracy of the scripting of questions for seizurelfitting calls. In particular, and in relation to code 12002 calls (post 19.6.19) the requirement for a healthcare professional to call back after 20 minutes of continuous fitting to trigger a call upgrade from Amber 1 to Red: In an @-mail from of 17/10/19 @ 7,11 and read to the Court; it was confirmed that the question is not currently asked of the caller to WAST, how long has the patient been fitting? This would appear to be a crucial piece of information in order to ascertain as accurately as possible; the known timing of the onset of the fit; for the purposes of determining when the 20 minutes elapsed: E.g: If it is known that the patient has already been fitting for 10 minutes, then the advice to call back should be in 10 minutes hence. If the fit has just commenced, then obviously; that advice can be for a 20 minutes call back: Cadelrydachalr Manin Woodlad Prl Wenhred ichict Executra Joson Kllcrs 4je Ymddinadohelh Cadtsaau Dohebuain yaly Gymtet) naut 5a61n9. 0C na hdd pohabu yl GyriBogya Ewah 0l 0edi Tho Irusl #ukomdt Atceondent M Wbbh 0 Enatth and Ial coretpomdtp h Wpbn winlbrd * 08aat 4$ Way. (

The improvement plan attached includes actions that lhe Trust is considering in relation to the code set 12C02. One of the actions will be t0 consider whether the Trust will move the code set into the Red (Immediately Life Threalening) category: This has already been previously been discussed and considered through the Clinical Prioritisation Assessment Software (CPAS) group, and is scheduled for further discussion in March 2020. However, before making any changes to code sets, the Trust has to consider the impact that such a change may have: This will include; for example what is the clinical rationale for making the change, an evidence base, patient outcomes and any potential detrimental effect the change may have on other codes. Also, the Trust is considering undertaking some external modelling through Optima (which is software modelling Ihat is used lo help make better decisions in health), on the potential performance impact of such a change may have: This will include the effect this change may have on Amber responses, if 12C02 moves into the Red category_ In addition, the Trust has also changed the guidance for prolonged fitting: This ance reflects that the call takers should stay on the line with all callers, ralher than asking Health Professional) (HCP) callers to ring back (I atlach copy of the current guidance for your reference) and calls should be escalated to a Red, in order to ensure the immediate dispatch of a suitable resource: The wider issue of whether a response from a healthcare professional (to question(s) posed by a call handler) that the patient Is not maintaining hislher airways should itself triggerlcategorise a continuous red code_ The evidence of at the Inquest; was that such scenario was of the highest clinical priority, as the patient had a high risk of cardiac arrest in such circumstances. There appeared some tension in the evidence surrounding the 12001/02/03 categorisation as to which code would be triggered on the volunteering; or otherwise of this indication from the caller. To inform my response, it will be helpful to provide some background information: Prior io 2014 all Heallh Care Professional (HCP) callers were asked if the condition of their patient posed an immediate threat t0 the patient's life. If the HCP gave a positive response, this resulted in an immediate Red 2 (now Amber 1) response being generated without any further questions asked, Unfortunately this resulted in HCP calls being given higher priority than patients in a similar or worse clinical condilion The unintended consequence could result in other patients adverse clinical outcomes. To overcome this, the Trust now use the questions through the Medical Priority Dispatch System (MPDS) to ensure that all patients across Wales are treated with parity, including HCP requests. HCP calls are consequenlly prioritised as Red where it is clinically appropriate. There are rare occasions, as a result of this change, when the MPDS will not detect the urgency of some; relatively rare; asymptomatic conditions. However, to overcome this the Trust has introduced within the Clinical Contact Centre guida Care being having

(CCC) a Clinical Support Desk with dedicated clinicians. Introducing clinicians into this environment enables HCP callers to request to have a clinician to clinician conversation if they feel their palient warrants higher priority of response: The actions to be taken when the urgency of the response after triage does not match the expectations of Ihe booking HCP due to the presenting condition include: Documenting any clinical information that has been provided by the HCP;
2. If a CCC clinician is available, to place the HCP call through to the CSD;
3. If no clinician is available the Emergency Medical Dispatcher (EMD) will immediately raise the call with their supervisor, or Duty Control Manager (DCM) ifno supervisor on The Supervisor or Duty Control Manager (DCM) will tag the call for review by clinician and ensure a clinician is informed. Whether pathway exists, or should be created for updating G4S the operators of Parc Prison with changes implemented by the WAST affecting call prioritisation: This is likely to have the benefit of ensuring that healthcare professionals at the prison are fully aware of what is expected of them in an emergency call to WAST and what response can be expected from WAST at the time an emergency call is placed_ As a All Wales Ambulance Trust we provide an all Wales service. The Trust operates three regional CCC's who work virtually across Wales, not servicing individual Health Boards or boundaries, with calls being answered by the availability of call handlers, rather than by geographical location of the patient. Therefore, the handling of emergency calls received, is pan Wales, without regional and or local variations. This principle is also true across all of the HM Prisons across Wales. Therefore; as requested, the Trust has considered if it would be appropriate to create bespoke pathways for Parc Prison or to introduce some local variation: However, after some consideration it is believed that this would not be an appropriate way forward: All emergency calls are unique in nature and will require a different response based on clinical need and the presentation of the patient. To introduce local variation could also potentially have adverse consequences for patients across Wales_ However, can provide you with assurance that quality improvements and changes have been made within the Trust: can confirm that we have improved the way in which (he Trust and HCP callers are able (0 communicate. The Trust has increased the number of clinicians on the CSD Further t0 this the Trust has introduced 2 new roles within the CCC and the CSD. The first role Call Taker Supervisor is a new role introduced in November 2018, with the purpose of supporting the CCC operating 24 hours a 7 days per week The second role is a shift lead within the CSD who will have oversight of the patients waiting on the 999 queue: This clinician can now view a list or queue of calls duty. being day

wailing for clinical input and has the ability to filter HCP calls waiting and can bring them to the forefront. In addition, with this expansion, we have been able to put escalation arrangements in place for HCP callers who require to have an urgent clinical discussion: Whether there or should exist; a clear pathway for between the Princess of Wales Hospital Emergency Department clinicians and WAST in relation to best practice for call categorisation. In particular, whether there should be regular input from the emergency department consultants at the Princess of Wales Hospital into the CPAS group for the purposes of assisting in relation to the appropriate categorisation of calls Whilst the Trust would welcome engagement from clinicians from Princess of Wales Hospital, the Trust provides an all Wales ambulance service commissioned by the 7 Health Boards across NHS Wales_ can assure you that the CPAS group which is chaired by a Senior Medical Consultant (Assistant Medical Director) has wide and varied clinical membership including representation from Patient Safety. The group also has & robust governance framework in place to ensure clinical decisions are documented. However; am able t0 provide you wilh assurance (hat the Trust uses the international Medical Priority Dispatch System (MPDS) which is an international, evidence and research based system used across the world to ensure that the calls are categorised and correctly prioritised, ensuring that patients receive the correct emergency response This is how all Ambulance Trusts provide assurance of best practice would again like to extend my sincere condolences to Mr Mclean's family on their sad loss. would also like to extend the offer t0 meet with you to discuss our response in more detail and t0 provide you with any further assurance you may require regarding our commitment to continuous improvement to support the prevention of future deaths.