GIG Partneriaeth CYMRU Cydwasanaethau NHS owasanaethau Oyfreithiol a Risg WA L E 5 Shared Services Partnership Legal and Risk Services Ffon/Phone: 029 2090 3769 Ebost/Email: Dr S J Richards HM Assistant Coroner Eich cyf/ Your ref: South Wales Central Area Ein cyf/Our ref: INQ I03 3461 ALF e The Coroner' s Court; Courthouse Street Dvddiad/Date: 01 October 2018 Pontypridd CF37 1JW Steven John Welch (deceased) This letter is in response to the two Regulation 28 Reports to Prevent Future Deaths that You issued to me on 7 August 2018 following the conclusion of the inquest into the death of the late Mr Steven John Welch at which one of my staff; represented both the Welch mbulance Services Trust and Cwn Taf University Health Board. Following the inquest] wrote by email to to provide him with contact details for the three health bodies involved in the care ofhis son; tO enable him to ask further questions directly if he wished. My role is as Director of the NHS Wales Shared Services Partnership Legal and Risk Services and the Welsh Risk Pool Service. Solicitors employed by Legal and Risk Services provide advice and support to all health bodies in Wales across a range of legal issues including clinical negligence and those relating to inquests. When requested by a health body, we assist in the investigation of the circumstances of a death; provide support in respect of the of witness statements and advise of the likely issues which will be the focus of a Coroner' s attention: During the course of the conduct of clinical negligence claims, including those where there has been or will be an inquest; it is common for US t0 recommend obtaining an independent expert opinion to identify those issues which may represent a standard of care which falls below that which is acceptable: on occasion; that expert identifies a real cause for concern which may affect patient safety. In those circumstances the content of the report is drawn to those senior clinical directors in the health body who are in a position to review the current provision of care and policies ad who will be able to make urgent changes where necessary. We are not responsible for ensuring those changes are made and nor do we seek t0 influence clinical decisions That is not to say that [ do not recognise the importance of Cyfarwyddwr Dlrector. Annc-Loulse Ferguson 4th Floor, Companles Hause Crown Way Mae Gwasanaethau Cylrelthiol & Cardiff CF14 3UB Risg yn IS-adran 0 fewn Partneriaeth Tel: 029 2090 3700 Cydwasanaethau GIG Cymr Fax: 029 2090 4146 Legal and Risk Services IS Lexcel DX: 124592 Cardiff (Co. House) division of the NHS Wales Sharcd Service Partnership L54eetke Quallty Mutt Law Soclety Aeredcd Mr taking

the work that we do to support the clinical teams to reduce harm to patients by our careful review of the internal and the independent reports obtained into care complained of: The Welsh Risk Pool Service has two primary functions: the first is to reimburse health bodies which have paid compensation and costs in respect of a clinical negligence or other personal claim made against it In order for the advisory board of WRPS to approve reimbursement; careful scrutiny of papers submitted to provide evidence of the lessons learned from the events to the claim is undertaken; notwithstanding that these events may have been some years before. Insufficient or unsubstantiated submissions are rejected and reimbursement deferred or even, in extreme cases refused, until clear; auditable action plans are produced: The second function is to provide support and assistance to health bodies in the provision of training to improve risk management and clinical standards: Staff spend lengthy periods undertaking reviews into issues which present as a trend in the claims reimbursement process, for example, review into the incidence and early identification of pressure sores_ The Head of Safely and Leaming of WRP is invited by health bodies to offer advice and assistance to clinical departments to improve patient outcomes; however we have no mandate to introduce any reforms or improvements ourselves The issue of the transfer of radiology between health bodies both within Wales and across the border will be scheduled into the current work programme: I believe that the legal and support services we provide to health bodies in Wales is proactive in helping them recognise and respond to clinical risks which we identify in claims and our investigations at their request but we do not have a place on their boards and have no influence or control to about service change which must be & matter for the boards themselves_ should be to meet with you to discuss my role and that of my team should that be of assistance.

Dear Dr Richards Re: Mr Steven John Welch (deceased) This is the response of the Welsh Ambulance Services NHS Trust to the Regulation 28 Report to Prevent Future Deaths that you issued to ourselves (the Trust) on August 2018 following the conclusion of the inquest the late Mr Steven John Welch Within your report you asked the Trust to consider and address the following specific issues: Tralning needs of 999 emergency call telephonists for medical assistance: can confirm that the call handlers , known as Emergency Medical Dispatchers (EMDs) , training schedule was last reviewed prior to the last induction of new recruils in July 2018. All trainees have to be signed off as competent before are allowed to go live within the operational service: The auditors within the clinical contact centre act as mentors t0 the new EMDs and are experts in the level of compelency required to take 999 calls. There is another group of staff who are responsible for allocating ambulance responses t0 incidents, these are called Allocators who dispatch the ambulance via the Computer Aided Dispatch (CAD) system. can electronically send a message Cadeirydd Dros Dro/nterim Chalr: Martin Woodford Pr f Weithredwrig /Chief Executive Jason Killens Moe Ymddirledolacth yn cresawu gohebbeth yn y Gymroeg neu'r Soesmka The Trust wekomes coriespandence In Welsh ar English Gre they They

to the vehicles t0 allocate them to an incident The Allocators are supported by Dispatchers who assist with meal break management;, vehicle breakdowns and radio communications etc We do not expect Alloca ators/Dispalchers to maintain their call taking skills unless are undertaking regular calls. If for any reason an EMD has not been call taking due t0 prolonged sickness or seconded t0 a different role would be expected to undertake refresher course and have their competency reassessed prior to commencing live independent call taking: The purpose of the Medical Priority Dispatch System (MPDS) Quality Assurance and Improvement is to ensure staff adhere to a standardised practice and procedure as defined by the International Academies of Emergency Dispatche (IAEDTM) when using their prioritisation software product The quality improvement audil process is inlended to support staff and identify learning needs as well as recognising performance strengths. Therefore, auditing calls is a vital function to ensure these standards are maintained. If any skills gaps are identified the EMD will receive extra coaching, be supporled with a coaching plan and capability may be considered if they fail to reach an acceptable standard following appropriate support. EMDs are required to underlake recertification 2 years, sit an exam and demonstrate they have undertaken 24 hours of Continuing Dispatch Educalion (CDE) in that time: With regard to the use of the breathing tool the Trust is and has been working wilh the International Academy of Emergency Dispatch (IAED) to try and improve the assessment of breathing over the phone: It is well recognised that this is very difficult to assess with callers and to aid EMDs the Breathing Verification tool has been developed. It is clear in MPDS guidelines that if there is uncertainty about whether the patient is breathing should act as if the patient is not breathing: If the patient is unconscious and is reported as breathing abnormally the caller is asked to check if can feel Or hear breathing: If the answer is "no" then Cardio Pulmonary Resuscitation is started: If the answer is "yes" the breathing will be further evaluated the Breathing Verification tool. The caller is asked to indicate every time the patient takes a breath to ensure the patient is breathing effectively: The auditors monitor the use of the breathing lool to ensure it is used correctly. Whilst the Trust does not propose t0 change its systems following the receipt of the Regulation 28 report, hope this reassures you that (he Trust does have in place systems for considering call takers initial training needs, as well as monitoring their ongoing performance, with built in occasions to identify ad act on remedial training needs. they being Ihey every very they they using being

The complexity of the emergency call ranking system (MPDS) for users and whether or not this may contribute to errors occurring: MPDS has been designed t0 generate a code in response to an emergency call: As am sure you will appreciate given the vast number of possible reasons for making clinical call ad clinical conditions that can exists, MPDS can generale 1,933 different codes. These codes are then matched to the 5 different categories of response (Red, Ambers and Greens) in the Clinical Response Model: MPDS has been designed t0 be screen driven thus making it easier for the EMD to use. It follows a 'flow chart' type system with one answer leading to the next question This depends on the EMDs correctly recording into the system the responses received from the caller_ In response to the Regulation 28 received from yourself we have undertaken a review of the calls taken for the first 6 months of the year to explore if there is any evidence to support the supposition that MPDS is too complex for call handlers t0 use effectively: Of the calls audited only 7% of calls were non-compliant: A total of 85% were of high compliance and in order to get a recorded result of high compliance the call taker has to have scored a perfect 100%. Number of Porcont Ceses High Compllance 85% 2990 Compliant 696 203 Partlal Compllance 296 60 Low Compliance 0% 15 Non-Compliant 796 247 Totals 100% 3515 From this data it can be concluded that the EMDs generally do use the MPDS software correctly: The audit data was examined to identify if there was any particular aspect of the call taking that the EMDs had difficulty with: No one aspect of call taking stood out as presenting an issue other than the delivery of Dispatch Life Support (DLS) instructions. Dispatch Life Support includes all instructions given during the call, this does not affect the category of the call. The DLS deviations relate to a moderate deviation_ Moderate deviations are those deviations from expected perfomance considered to be incongruent with the desired function and design of the protocol without a direct impact on safety These deviations can affect the most appropriate instructions provided, but are not expected to have a direct negative impact on the patientlvictim or scene outcome. On each of the critical deviations 97% or more of the times the calls were managed corectly. critical deviation are those deviations from expected performance that not only fall to meet the minimum standard of practice but also pose a substantial risk to the caller Or patientvictim Or that impact responder safety: Examples of critical deviation can include the address not being verified correctly, even if the correct the they

address was given, failure t0 choose the correct chief complaint; however this might not affect the final categorisation. So although will be marked as critical it does not always follow that patient came t0 harm Having reviewed this evidence the Trust does not belleve the EMDs find MPDS too complex to use. The Trust will continue to monitor the EMD's perfomance MPDS and continue t0 work t0 improve call takers performance: Petcrnlant 0l Drvtelion, Critkru Hakot Hodttan 4ux Cax Eray noang} It [114 tebt DuL Chin Coneti M9ust J Um" B (Iua Ke Outtud Homay 4t Qu% D* Oiur Dupsich Le Surpor Keayy (in 0AIL JE Ha Fndl Coto Adtny 7]* Wr uout I1dc Curonet Stnkt Aoanty r 0is 01S 0jnD Tobe Mcndizuon Actldlnd Mntnty Ienae 0307 0148 U718 The Trust is an MPDS Centre of Excellence, one of only 250 such centres worldwide: This is from pool of over 2500 the system: Annually, MPDS is used in the prioritisation of 65 million Emergency Medical calls worldwide and has been shown to be a safe system: The failure to predict accurately emergency demand over public holiday thereby not having sufficient resources at hand or in reserve: As described al the Inquest the Trust currently uses the previous year $ emergency demand profile, with percentage uplift when trying to predict the daily emergency demand. The Trust is aware of the need to consider changes to the demographics in Wales, bolh current and predicted, and as such the Trusts Planning & Performance Directorate, since July 2018, have been working on project in relation to Optima Predict. Optima Predict is powerful interactive strategic planning solution for Emergency Medical Services (EMS) that provides a platform to undertake Operational Demand & Capacity Review: they the using using

Optima Predict takes into account key performance indicators (KPIs) such as response times, vehicle coverage and shift requirements and allows users to quickly build scenarios that make logistical and business sense: It can be used t0 estimate call volumes, for the coming year and beyond, test different coverage and posting plans, test proposed roster changes and then analyse their impact, enabling the Trust t0 select the most effective option and take action_ The project is ongoing and the Trust is currently modelling the plan for Optima Predict and the issues that will be selected for analysis: hope this reassures you that the Trust is taking action to address and further strengthen future planning by using this software. The use of the software will assist the Trust in planning the utilisation of available resources t0 inform our Integrated Medium Term Plan: The Trust has also undertaken the recruitment of 90 additional staff; who are undergoing training and will be operational by December 2018. Whilst the increase in staff is pan Wales, a proportion of the new staff will be operational in the Cwm Taf area. This will enable the Trust t0 increase the number of staff available to it and the number of staff that can be considered as being available "in reserve" , although we are obviously restricted by the number of vehicles available and available budgets: The impact of lengthy patient handover delay times between emergency ambulance and recipient hospitals, upon the delivery of an effective emergency service. The Cwm Taf University Heallh Board (the Health Board) and the Trust already work closely together t0 minimise delays in hospital handover and ensure patients receive the care need in timely manner: The Health Board can experience occasions when the number of ambulances arriving at the emergency unit temporarily exceeds the capacity of the unit t0 safely receive the patients, leading to a in handover from the Trust's crews. We are very aware that these waits are not only sub-optimal for the patient on the ambulance at the time but can also affect the ability of the Trust to respond to patients in the community: For these reasons we endeavour to keep these delays to an absolute minimum and closely monitor our performance on an hourly and daily basis. It should be noted that Cwm Taf University Health Board is commended for their focus on flow improvement model that has achieved the least lost hours for hospital handover from the Trust in NHS Wales_ Whilst our colleagues at the Health Board will share with you the actions are taking to continue to minimise handover delays, in response to the Regulalion 28 report you issued separately t0 them, would like to assure you that the Trust also continues to try ad avoid conveyance of patients to the Emergency Departments when it is safe to do so. Whilst the following actions do not directly affect how long ambulances take to hand over the care of patients when they arrive at hospitals, these actions see a reduction in the number of patients being conveyed to Emergency Departments across Wales and improve the flow of patients within the NHS. Please find appended to this response further details of these supporting actions. they delay they

The Trust has developed robust winter planning actions that will support the requirements of this Regulation 28 report received from you: We would Iike t0 reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board continue t0 work together to drive the improvements and learning forward that we commenced last year and we continue to strengthen the out of hospital alternative pathways t0 improve efficiency and effectiveness of care for our patients ad make best use of our resource. In conclusion: We hope that we have been able t0 assure you that as a result of the Regulation 28 the Trust: Has in place robust systems for the training of call taking staff and systems for the continued monitoring: Has undertaken a review of errors made by call takers in the last 6 months and the findings provide assurance that the complexity of MPDS is not contributing to the erors made. Will be using the Optima Predict software to assist the Trust in more accurate predictions in relation to emergency demand and resource deployment: Continues to work collaboratively with Cwm Taf University Health Board to further reduce patients being conveyed by ambulance to the Emergency Units, increasing the capacity of appropriate resources and assisting in patient We would like to extend the offer to meet with you t0 discuss our response in more detail and to provide you with assurance of our commitment to learning ad the continuous quality improvement our service provision: