Dear Mr Gittins Re: Regulation 28 Report to Prevent Future Deaths Inquest of Sarah Ann Tyler (DOB 21.04.75 DOD 11.02.15) We are writing in response to your Report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013, dated 13th January 2017 _ There are two matters of concern set out in the Report of 13th January; That there are invariably delays in admission to hospital as there are insufficient beds available to accommodate all admissions. 2 That the issue of "bed blocking" is more acute at weekends due to reduced numbers of patients being discharged from hospital Introduction The Health Board recognises the need for improvement and the importance of ensuring that inpatient beds are available when required for new admissions_ Waiting times for new attendances at the Emergency Department are monitored through the Welsh Government target for patients being treated or admitted within 4 hours_ During Q3 2016/17 78.9% of patients were treated or admitted within this time. Whilst the majority of patients are treated or admitted within the acceptable time, a significant minority took longer to be treated or admitted and a proportion of these will have waited significantly longer. The Health Board is required by Welsh Government to have a plan in place so that performance against the 4 hour target is improved, and that more patients are treated or admitted within 4 hours The plan to achieve this improvement is set out in the Health Board's plan for Unscheduled Care Plan, which is a chapter within the overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached in appendix 1 (The plan is a draft at this stage pending feedback on the draft from Welsh Government) Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr Executives' Office Carlton Court; St Asaph Business Park St Asaph LL17 OJG Gwefan: Ww:pbc cymru nhsuk Web: wwWbcu.wales nhs.uk

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board W A L ES The Unscheduled Care Plan (appendix 1) The Unscheduled Care Plan sets out the main changes planned to ensure that waiting times in the Emergency Department are reduced. The plan describes a change in the overall approach to providing Unscheduled Care services, which will ensure that there is both less reliance on admission to hospital in order to receive treatment or care and faster discharge from hospital when patients could be more safely cared for in another setting or at home. The combined effect of admission avoidance (reducing demand) and reducing length of (increasing the supply of available bed days) beds will be available more quickly for patients when are most in need_ Admission Avoidance Patients attend ED as a method of gaining access to health services. The Unscheduled Care plan sets out the overall approach to ensuring that wherever possible, patients can be treated without requiring admission to a hospital bed. The plan describes how community services and hospital services will be provided jointly so that patients will be provided with the same community services, irrespective of whether present to our services through the GP or via the Emergency Department For example, if a patient who is already known to community services attends ED, the District Nursing team are automatically informed and will attend to review if the patient can be cared for at home. This change was implemented in February 2017 at the Maelor hospital and is an example of measures being introduced to ensure that; wherever possible, the community and hospital teams will work together to ensure that patients are care for at home: Further detail on the admission avoidance programme and the targets for improvement are included within the Unscheduled Care Plan: We do recognise that it is unsatisfactory for any patient to wait for admission and do undertake to assess every patient waiting in an ambulance as soon as possible after arrival and at 30 minute intervals thereafter_ This triage assessment is undertaken by a skilled triage nurse and at times by an emergency department doctor: Where clinically required we will prioritise the sickest or most unstable patients for transfer into the department and ensure that patients and those with them are offered refreshments while are waiting: We also undertake a daily retrospective review of all patients who have waited in an ambulance for longer than an hour: We continue to review this process in order to minimise the inconvenience and eliminate harm_ Reducing Length of Stay In addition to the work to reduce admissions, there is also a significant focus on reducing the time spent in hospital for patients that are admitted. Patients who experience a Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a support package to be provided in their own home. The Health Board carried out a detailed joint assessment of the issues that cause delay in December 2016 jointly with Local Authorities and the Independent Sector providers of care services (care home and home care). The plans to reduce DTOCs and length of are set out in the plan_ stay they they they stay

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA L ES Bed availability at weekends The Health Board does also ensure that doctors and discharge teams are available to support at weekends but; in the absence of a whole scale change in working practices_ there will continue to be differences in the way that the hospital operates on Sunday compared to other days in the week_ The main Health Board response to this issue is to ensure that the overall level of bed occupancy is reduced_ The availability of hospital beds at weekends is largely depended on how well the system operates throughout the rest of the week: The aim of the Unscheduled Care plan is to ensure that there are beds available at all times and the recognised standard for the level bed occupancy required to achieve this is 85% Bed Occupancy. This means that there are 15% of beds available for new admissions and achieving this level of occupancy enables the hospital to cope with a level of natural variation in activity over the weekend_ The combined approach of reduced admissions and reducing length of has been modeled to enable the target level of bed occupancy to be achieved_ The Unscheduled Care Plan sets out the targets set by the Health Board in each section of the plan and the whole of the plan will be implemented within 2017/8. The implementation of plan will be overseen by the Health Board wide Unscheduled Care Transformation Group, which is supported by local implementation groups and projects charged with delivering each element of the plan: There will be monthly updates within the Health Board on the progress of the plan and progress against plan will be monitored by Welsh Government The Health Board is determined to improve the experience of patients that require urgent admission to hospital and the Unscheduled Care Plan sets out that changes that will be implemented to ensure that his will be achieved_ The implementation of the Unscheduled Plan is an important element of the overall Operational Plan to improve operational performance and the Health Board will be performance managed by Welsh Government over the delivery of this plan: Please contact us if you require any further information.