Dear Mr Gittins Re: Report for the prevention of future deaths Inquest of Daphne Edith Williams This is a joint response to the Report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013, dated 25th May 2017 for Daphne Edith Williams, which was issued to Betsi Cadwaladr University Health Board (BCUHB) and Welsh Ambulance Services NHS Trust (WAST): This response has been prepared collaboratively between BCUHB and WAST. The letter outlines the actions being taken in response to the matters of concern you outlined in the recent Regulation 28 notification for Daphne Edith Williams , namely; ambulance delays, admission to ED, availability of resources and patient All agencies are also aware of other Regulation 28 notifications that have been issued relating to patient flow issues to BCUHB, Local Authorities and WAST for Lilly Baxandall (17th May 2017) and to BCUHB for Catherine Haf Roberts (7th
2017) to which the actions outlined within this letter also apply, but for which separate formal responses will be submitted from the relevant organisation(s) The local authorities have not been party to any involvement regarding the previous reports issued and are therefore unable to comment on the content of the responses previously sent or indeed the actions referred to_ (Please note, the local authorities will comment later in this response on those areas that may be of assistance to support cases such as these:) In reviewing the action plans already submitted in response to previous Regulation 28 reports relating to patient flow, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau: After consideration of this_ it was not deemed feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling admission of emergency patients to as local a hospital as possible, as often as possible. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr Executives Office Ysbyty Gwynedd, Penrhosgarnedd Bangor; Gwynedd LL57 2PW Gwefan: wwW:pbc cymru:nhs.uk Web: www.bcu.wales nhs.uk flow: July the

GIG Bwrdd Iechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA L E $ In response to the matters of concern raised in the Regulation 28s for Daphne Edith Williams, BCUHB and WAST have structured their response along key elements of the patient pathway, these being: Avoidance of Ambulance Conveyance Emergency Department (ED) attendance Hospital Admission Improvement in Handover Times of patients conveyed to EDs by Ambulance Improvement in ED patient flow and timely assessment of patients Improvement in internal hospital flow to ensure more rapid admission of patients from ED who require this Improvement in the dischargeltransfer of care of patients at the end of their acute hospital stay: Our response reflects and compliments the actions outlined in the BCUHB 2017/18 Unscheduled Care plan: BCUHB also recently held 3 Unscheduled Care Summits with clinicians and colleagues from partner agencies to discuss and agree specific focussed actions to improve the provision of unscheduled care services_ In December 2016 the cross sector chief executives issued a directive for a detailed analysis of the care sector pressures resulting in an intensive 5 work programme led by Director's in both health and the local authorities, This work resulted in comprehensive action plan which is in place to address some of the blockages in the system that contribute to delayed discharge. In addition through the spring and summer 2017, BCUHB, WAST and partners have held a number of events with frontline staff to examine, explore and find solutions to the current service pressures; these were called Innovation Unblocked: Through these engagement events staff have identified very practical solutions of how systems can be improved to support These events have also identified key pathways that need to be developed to avoid hospital admission or to improve patient access to the right services avoiding unnecessary attendance t0 the Emergency Department_ To compliment this work; the Delivery Unit (DU); is also supporting BCUHB to implement improved risk escalation systems in managing unscheduled care demand. This is initially focussed on acute hospital sites to increase patient safety: The DU is initially focusing on providing this support at Ysbyty Glan Clwyd.
1. Avoidance of Ambulance Conveyance ED Attendance/Hospital Admission In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed: This sought to ensure that patients and users of the service received the most appropriate care and response to suit their individual needs_ The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time AII other patients receive a bespoke clinical response based on their condition, rather than a response based solely on a time standard. These changes sought to improve the patient's care, outcome and experience, as well as improve patient into hospitals: day key flow. flow

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board W ^ L ES WAST has been working with BCUHB to develop new services and alternative care pathways: Latterly, this has included holding series of joint; clinically focused workshops across North Wales to review, identify and implement new emergency care pathways that WAST can access, some of which have been agreed in other parts of Wales The final workshop took place on 7th July following which number of key innovations, work streams and care pathways been prioritised _ A clear priority identified will include having a focus on improving the management and care of patients who fall at home (referred to separately in more detail later in this section of the response): The detail of the Unblocking Innovation events is attached as Appendix 1_ In addition, and in line with the BCUHB Unscheduled Care Plan 2017/18, WAST has been focusing on: Increasing Conveyances to Minor Injury Units to reduce demand on EDs Increasing the effectiveness of the WAST Clinical Support Desk Improving support for frequent callers to WAST to reduce ambulance conveyances to hospital: Developing the provision of alternative care pathways Enhancing WAST Clinical Leadership
1.1 Mingr Injury Units (MU) The Head of Operations for WAST has been leading work with BCUHB to increase the access to and use of MIUs by WAST, supported by a joint steering group which aims to: Ensure a nurse led MIU service is available across all of North Wales Improve patient access Review and extend the admission criteria Extend opening times, particularly over the periods Launch an App" to ensure that the opening times of the MIU are publicised for WAST responders and the public. The next steering group meeting is planned for September 2017 when work to date will be reviewed to ensure progress in all areas_
1.2. Increased effectiveness of the Clinical Support Desk As the result of a service improvement initiative, WAST has invested in a Clinical Support Desk within the Clinical Contact Centre (CCC) This means that clinician (nurse paramedic) is available to clinically assess, through telephone triage, the needs of patients and advise on appropriate alternative care pathways or conveyance_ This initiative has proved highly successful, resulting in an average of 2,500 calls per month having non-ambulance outcome thereby substantially reducing ambulance conveyances to hospital Following the success of this initiative, WAST has successfully presented business case to the Ambulance Services Commissioner and Welsh Government and has received funding from Welsh Government to increase the clinicians employed in the clinical support desk for up to 30 whole time equivalents. Some clinicians are now located on the North Wales Clinical Support Desk in the CCC. have busy

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA L E $ 1,.3. Erequent Caller Initiative A number of patients repeatedly access the 999 emergency ambulance service where alternative care may be more appropriate for them. These individuals often have complex health and or social needs and may have disengaged from appropriate care services Across Wales, WAST has already worked successfully with other Health Boards to provide appropriate alternative care for frequent callers within communities without the need for a conveyance to ED. Ajoint work stream between WAST and BCUHB has now been established to introduce similar service in North Wales_ 1,.4_ Provision of Alternative Care Pathways WAST and BCUHB are working together to proactively manage more patients within the community setting, reducing unnecessary conveyance of patients to hospital. During quarter (April, May, June
2017) the Ambulance Quality Indicators confirm that conveyance rate of 64-65% of patients to hospital across BCU. This is the lowest conveyance rate across all Health Boards in Wales: Examples of improvement work to achieve include the management of patients who fall at home, patients with mental health need and the implementation of the Paramedic Pathfinder: Falls: The Clinical Support Desk is working collaboratively with Wrexham Fire Service and North Wales Police to provide care and assistance to non-injury fallers within the community setting: The fire service will respond and assist the patient and while doing so, undertake preventative work including surveying the house for any immediate fall hazard risks, security and fire prevention: As a result of the joint clinical workshops referred to earlier in this response, WAST and BCUHB will implement a North Wales wide falls pathway by the end of October 2017 . WAST has established a falls strategic improvement group to focus on improving the assessment and response to patients who have fallen across the 5 model to inform once for wales' approach to falls_ Mental Health: As a result of both service user and staff feedback,; WAST has developed a Mental Health Improvement Plan outlining 6 priority areas for those with mental health needs_ This includes supporting WAST staff through the use of an assessment of the patient's mental health illness or mental distress. This will be based on using up to date evidence based education and training and developing risk assessment tools for frontline clinicians to support their decision making: In addition, key priority is to develop alternative care pathways for patients experiencing mental health distress to ensure that wherever appropriate conveyance to an ED is avoided. In other parts of NHS Wales, WAST has successfully developed joint pathways with mental health crisis teams_ This learning has been shared with step

GIG Bwrdd lechyd Prifysgol cYMRU Betsi Cadwaladr NHS University Health Board W A L E $ BCUHB and informs joint work underway to develop and implement this care pathway within North Wales_ This approach will need to be discussed further with the local authorities_ Paramedic Pathfinder The demand for emergency ambulance attendance is increasing year on year: patients can be treated through safe alternatives to transportation to an ED: Paramedic Pathfinder has been designed to support ambulance clinicians in assessing patients in the pre-hospital environment_ It does this by enabling the exclusion of serious discriminators before any consideration is given to an alternative pathway of care other than conveyance to an ED. WAST is currently undertaking a trial of the Manchester Triage System (decision support tool) in the Abertawe Bro Morgannwg University Health Board area. This will be evaluated for potential future roll out across Wales to inform alternative pathway development
1.5. Enhancement of WAST Clinical Leadership priority area for WAST, identified in the service's Integrated Medium Term Plan, is the development of its paramedic workforce. Following the changes to the WAST clinical response model outlined earlier, the service is becoming a more clinically focussed service, requiring the complimentary development of a clinical leadership structure to support paramedics to work their full scope of practice_ This will in turn enable them to identify more patients suitable for alternative care pathways to conveyance to ED. This work has already commenced with the appointment of" new Assistant Director of Paramedicine_ Complimenting this work by WAST are a range of BUCHB initiatives to reduce ambulance conveyancelIED attendance_ These include: Introducing Treatment Escalation Plans (TEPS) to reduce the number of people brought to EDs by ambulance from nursinglresidential homes. These plans outline alternative care pathways and treatment options for individuals to manage them safely in their residences Developing enhanced multi-disciplinary community resource teams (CRT) to provide more care for individuals in their own homes. The CRTs are in varying degrees of development across North Wales and whilst have the potential to better manage care closer at home need to build on the range of successful intermediate care provision already delivered in the 6 local authorities__ Developing a range of alternative care pathways including for catheter management;, palliativelend of life care at home or in nursinglresidential home and work with WAST to develop a number of alternative care pathways including one for falls (see below). One authority already provides a successful palliative care service on behalf of the health service and the local authorities are keen to enhance services could be commissioned to provide Many key they

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA4 E $ 2 Improvement in Handover Times of patients conveyed to EDs by Ambulance BCUHB has developed an escalation protocol to ensure consistent approach to the safe management of patients whose handover is delayed: This is to support the procedure to enable the immediate release of delayed ambulances to enable WAST to respond to life threatening or clinically urgent 999 calls in the community (the immediate release system): With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which clearly outlines the escalation processes for WAST and BCUHB staff to apply to enable ambulance crews to hand over patients to ED with minimum delay. As part of the 'LEAPF protocol, WAST provides Hospital Ambulance Liaison Officer (HALO) or Duty Operational Manager (DOM) at hospitals when ambulances are delayed. These are usually WAST Clinical Team Leaders whose role is to supervise crews experiencing handover delays and Iiaise directly with ED. The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity: WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance_ For Ysbyty Glan Clwyd, patients who cannot be immediately accommodated into clinically appropriate ED space will undergo a triage assessment by an ED nurse and clinical medical review. Patients held in an ambulance for an hour or more will have a full 'harm review to commence assessmentltreatment and ensure their care outcome is not compromised_ The recording of patients' vital signs including the National Early Warning Score (NEWS) is routinely recorded as part of these assessments and is integrated into the paramedics' patient record. At Ysbyty Maelor Wrecsam , holding area in ED is created whenever possible during the to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical 'RATS' (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.
3. Work to Improve Assessment Times Flow in ED BCUHB constantly reviews its clinical and operational processes to improve waiting and assessment times for patients and to admit patients in timely manner to an inpatient bed where this is required BCUHB acknowledges there remains much work to do but examples of more recent improvements are outlined below good day

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA L E $
3.1. Ysbyty Glan Clwyd A review of the use of the physical space within ED has created an open ambulatory chair centric area with additional assessmentltreatment spaces; the commissioning of 2 additional beds in the observation bedded area f the ED; the use of the co-located GP Out of Hours area during the (Monday to Friday, 9am 5pm) to provide 4 rooms for assessment treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure A further review of the physical layout of the ED is underway to identify space to create firstly an area to rapidly assess patients handed over by WAST (RATS) and secondly to better manage the 'minors in ED to improve the waiting times and assessment of these patients. On-going recruitment of nursing and medical staff is a key focus_ This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staffto all posts although recent recruitment campaigns for senior medical staff have met with success It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible. The service is also working towards better matching senior medical staff working hours with times of peak patient demand_ The aim is to the Consultant late day shift extended from
18.O0hrs to
22.O0hrs and have second Consultant working until 9pm Monday to Friday Work is also underway with the co-located GP Out of Hours service in the ED department to identify more suitable patients through the triage of self-presenting patients to ED for 'pull' into the GP Out of Hours service A time GP , Monday to Friday, is also in place in ED to treat primary care presenters to ED. Work is also on-going to increase specialty 'in reach' into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward_ This does result in some patients being discharged home from ED.
3.2_ Ysbyty Maelor Wrecsam The recruitment of medical staff is ongoing to improve cover of the medical rota August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies currently covered with locum Consultants_ There is a focused campaign of work ongoing to recruit to these posts on a permanent basis The recruitment of nursing staff has been successful. However, retention of staff remains a challenge with the senior nursing team focussed on maintaining patient safety in ED. day" flow have day self- from key

GIG Bwrdd lechyd Prifysgol cYMRU Betsi Cadwaladr NHS University Health Board w AL ES Medical and nursing staffing rotas have been reviewed and amended to better reflect the peaks of patient demand in ED and changes have also been made to increase the senior level cover in the department The ENP service has protected staffing and clinical space to ensure patients with minor injuries are treated in a timely manner: 3 additional rooms in ED been opened for Minors patients, the ENP service and GP Out of Hours Services_ Work is also underway with the co-located GP Out of Hours service in the ED department to identify more suitable patients through the triage of self-presenting patients to ED for 'pull' into the GP Out of Hours service. There is specialty 'in reach' into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home ED_ Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues 4_ Work to Improve Site Flow across Ysbyty Glan Clwyd / Ysbyty Wrexham Maelor Much work is also on-going to admit patients in a timelier manner into inpatient beds ED. As with service improvements in the EDs, BCUHB acknowledges there remains work to do but examples of recent improvements are outlined below:
4.1. Ysbyty Glan Clwyd modified form of unified assessment documentation for patients awaiting admission from ED has been under development: This supports the provision of inpatient level type care to ED patients, ensuring their clinical outcomes and treatment is not compromised. It is intended to fully introduce this process in early August; following period of trial to ensure all documentation and processes are fully fit for purpose_ In early autumn; Frailty Assessment Unit will be trialled, providing more comprehensive assessment of frail patients at the 'front door' with the aim of avoiding admission for some of these by providing additional community support to enable patients to be safely managed in their own homes This needs further discussion with the local authorities_ During times of peak demand, additional 'surge' inpatient bed capacity is opened in line with available staffing: This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely: Down' Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay (this may be: placement in a nursing/residential home, transfer to a community hospital or back to their own homes with packages of support): However local authorities already provide swift discharge to social care packages and often the have from from 'Step

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board W AL ES choice of the patient in relation to their preferred care settings can contribute to delay.
4.2 Ysbyty Maelor Wrecsam From the 1st August 2017, rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with Frailty Assessment Unit with focus on admission avoidance to return individuals to their own homes with the support of community staff; including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours_ Patients will be treated as ambulatory until proven otherwise and within the unit; individuals will receive rapid diagnosis and stabilisation before they are supported home The ethos of the unit is to proactively diagnose and treat patients; to prevent deterioration that could lead to an emergency admission; and, to refer to the appropriate community services to support patients in their own home during their need for support During times of peak demand, additional 'surge' inpatient bed capacity is opened in line with available staffing: This includes the escalation of additional beds on some wards where staffing levels enable this to be done safely. The District Nursing Service in Wrexham is now available overnight; enabling more patients to be safely cared for at home rather than remain in hospital. The provision of an IV suite continues to develop as an important service to enable individuals to receive IV therapy as attender (both emergency and elective) without the need for an overnight hospital stay. In times of extreme pressure, additional holding areas are staffed away from ED to assist with the pull through of patients from ED to sustain flow of emergency patients_ A proposal has also been drafted to provide a Clinical Manager of the week, in addition to the Clinical Site Manager model already in place_
4.3. SAFER BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months_ This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are: A daily senior review of all inpatients (S) AIl patients to have an expected date of discharge (A) Patients are moved out of assessment areas earlier in the day into inpatient specialty wards (F= A third of patients being discharged leave their ward before midday (E) Regular review of patients who have been in hospital for 14 days or more to identity actions required to facilitate safe discharge (R) This was endorsed by the National Unscheduled Care Board and implemented locally. A number of elements are already set up (such as reporting measures i.e Expected Date of Discharge' with work ongoing to fully implement the patient flow bundle, with day Day, day: key '),

GIG Bwrdd lechyd Prifysgol CYMRu Betsi Cadwaladr NHS University Health Board WA L E S senior clinical leadership at the helm, and supporting communications. The objective is to align actions of ward teams (Nursing, medical, therapy and partners) more closely and deliver actions earlier; this should result in improvements to length of (LOS) and therefore flow_ Medical leadership is vital, and job plans will be reviewed in some cases. measures will be: Numbers of discharges before 12.00 midday Compliance with Expected date of discharge (with expectations that this should be 80% on wards, allowing for new arrivals) Length of stay guide for the SAFER patient flow bundle produced by Welsh Government is attached at Appendix 2 for information_
5. Improvement in the dischargeltransfer of care of patients at the end of their acute hospital As well as the actions outlined above, BCUHB works collaboratively with WAST and Local Authorities to support the safe dischargeltransfer of care of patients following their acute hospital to ensure patients don't remain in hospital longer than require. At both Ysbyty Maelor Wrecsam and Ysbyty Glan Clwyd, there is a strong focus on early identification of patients who are medically fit for discharge to ensure timely discharge. Daily 'board rounds are held across acute adult wards to ensure daily discussion of each patient and their care needs, including discharge planning as appropriate with local authority colleagues_ There is weekly review at both hospital sites of patients experiencing a 'Delayed Transfers of Care' (DTOC): Healthcare Inspectorate Wales is soon due to commence patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process_ WAST is currently developing 'Patient Transfer, Discharge, Routine and Repatriation Guidance' to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their dischargeltransfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls_ Whilst the Regulation 28 for Daphne Edith Williams was not issued to Local Authorities _ the response that the four Local Authorities provided in relation to the Regulation 28 issued for Lilly Baxandall, outlines the relevant work that is ongoing to prevent and reduce inappropriate admissions and reduce delayed transfers of care. stay Key stay: stay they

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board W A L E $ 6 Concluding Remarks We trust this joint response from BCUHB and WAST outlining actions being taken across the patient pathway provides you with the assurances you require in response to the matters of concerns raised within the Regulation 28 notice issued for Daphne Edith Williams: All organisations are committed to working together;, sharing learning and making service improvements to improve patients experience and outcome of care_ Clearly as partners working together we prioritise effective hospital discharge services and just as importantly preventative services. However we need to acknowledge that there are some frailties in the provision of care due to national pressures impacting on care home and home care providers_ These do pose some risk to the service which have been acknowledged on regional and national basis_ We collectively acknowledge the multi-faceted system changes required by all organisations in North Wales and will continue to work together collaboratively to improve the services we provide to our patients and the wider local populations. Please do not hesitate to contact us if you require any further details or have any additional areas of concern_