Dear Mr Gittins Re: Report for _the_prevention of future_Deaths Inquest ofFrederick Douglas Pring We are writing in response to your Report pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013, dated 21 January 2014. We would like to confirm the actions taken by the Welsh Ambulance Services NHS Trust (WAST) and Betsi Cadwaladr University Health Board (the Health Board) in accordance with your Report: The actions being taken by the Trust and the Health Board in relation to the three points you have raised within the Regulation 28 notification are listed below: That the categorisation of calls and the prioritising of the allocation of resources does not currently appear to take into account the issue of delay and the potentially catastrophic impact of delay on both the patient and those seeking to care for him or her without medical assistance. The WAST utilises the Medical Priority Dispatch computer based prioritisation System (MPDS') to prioritise responses to emergency 999 calls. MPDS has been developed over the past 30 years, and provides a consistent and precise, evidence based approach to prioritising each 999 call: It is a system that is most widely used by UK ambulance services. Response to John Gittins, HM Senior Coroner NHS Cadeirydd/Chair: Mick Giannasi g Prif Weithredwr/Chief Execulive: Price-Morris GIG Mae'r Ymddiriedolaelh yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg Poe CYMRU The Trust welcomes correspondence in Welsh or English Blald , About SiTIVe _ 1 Elwyn OISABLe9

This system is regulated by the International Academy of Emergency Dispatch (IAED), who provide an overarching and robust clinical governance structure by Which MPDS operates, is governed and remains credible. These international standards of prioritising emergency calls provide WAST with the capability to safeguard its quality of patient care, by sending the appropriate emergency medical services (EMS) response to 999 calls_ MPDS operates by having thirty three call handling protocols, which are designed to identify a prioritisation code (ranging from 'ECHO' codes immediately life threatening situations requiring Advanced Life Support by EMS; to OMEGA codes calls that can be referred to other health and social care providers). Based upon prioritisation code, which is set by the IAED, each service using MPDS has to stipulate the type, number and mode (.e: with blue lights or non blue lights) of response to incidents. As per the recommendations of the IAED, ratification of the type of response (based upon the MPDS code) remains the responsibility of the individual Trusts Medical Director. Historically, WAST has adopted same responses to MPDS codes that were set by the Department of Health (DoH) for other UK Ambulance Services_ The only amendment to this has been that WAST has reserved the right to 'upgrade' responses (ie_ use of blue lights) , but never 'downgrade' responses In addition, where it becomes evident that a patients condition has deteriorated following further contact with a caller; the call taker reprioritises symptoms utilising MPDS, resulting in the allocation of a higher tier of response The call taker will also provide further telephone advice (e.g: on how to perform chest compressions in a cardiac arrest) until such time that an ambulance arrives at the incident: As a result of Welsh Government issuing new National Ambulance Performance Standards (December 2011) WAST introduced its Clinical Response Model. This model aims to focus on providing timely and clinically appropriate response to patients_ It maximises resource availability to respond to the most seriously illlinjured patient This is achieved by utilising response configuration which is closely aligned to the fundamental principles of the National Academy of Emergency Medical Dispatch and the use of the MPDS system: The standards require that the categorisation of 999 calls is based upon two definitions: Immediately life threatening (Red 1 & 2 responses; 8 minutes) Either serious but not life threatening or neither serious nor life threatening (Category C: Green 1 2 & 3 responses; 30 minutes) The Welsh Ambulance Service's Response Model unlike our English counterparts combines Green and 2 as a face to face 30 minute response_ The Clinical Response Model,; which drives resource allocation, recognises thatat times demand can outstrip available resource and sometimes there are no resources available to send to more life threatening calls The response model in these circumstances specifies that if the closest resource is already mobile to a lower acuity call, it must be stood down by an allocator and diverted to the more serious life threatening calls. If the closest resource is already on the scene of a lower acuity call the crew must be contacted and asked if they are able to attend a more serious call. 2 Response to John Gittins, HM Senior Coroner the the

Once calls are prioritised by the Emergency Medical Dispatch (EMD) call taker the calls are placed on a stack and allocated in order of acuity and time received Where there is a delay in sending ambulance resources EMD call takers are trained to support the caller and provide telephone instructions until trained help arrives. This can only be effective if there is no prolonged delay in response_ Other measures in place when demand outstrips available resources are cross boundary support from other ambulance localities in Wales and cross border ambulances services in England: The Trust recognises that these measures_ whilst maximising available resources, do not take into account delays in allocating response Bench marking with other United Kingdom Ambulance Trusts has identified that their clinical response models have been adapted since 2012, to provide a broader scope of categorisations and thus greater flexibility in identifying and responding to higher acuity incidents_ WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and Iower acuity calls. The Trust will identify MPDS codes that are definitely serious, not life threatening but requiring urgent on-scene assessment;, treatment and conveyance, with the intention of decreasing the Green 1 response time for these incidents from 30 to 20 minutes_ This will provide an opportunity to declassify some current Red 2 responses to Green Additionally, the Trust will review the determinant codes currently receiving a Green response, with the intention of moving them, where clinically appropriate _ within the dispatch table to Green 2 status providing either a 30 minute response or immediate telephone assessment where it is deemed clinically appropriate. In line with our Clinical Transformation strategy, Clinical Hubs will be established in our Clinical Contact Centres comprising multidisciplinary teams in order that secondary clinical triage can be undertaken to augment the AMPDS system In line with the strategy, we have already introduced Advanced Paramedic Practitioners in the Clinical Contact Centres to support patient safety and reduce any potential clinical risk These measures will more clearly identify life threatening incidents, highlighting their priority for dispatch during periods of resource delays. Further detail describing this development more fully can be provided if helpful to the Coroner: The Trust will undertake to keep the Coroner updated periodically on the implementation of its Clinical Hubs.
2. That the Rest Break Policy generally, but particularly in relation to the standing down of the crews whilst returning to base for mandatory breaks, may result in an unacceptable diminution in available resources and to this end would positively encourage greater degree of sharing of NHS facilities between Health Board staff and Ambulance staff s0 as to minimise where possible, the need to return to base. The Trust Board has resolved that; in future, workforce policies must be constructed from an objective point of view; must be defensible and stand up to public scrutiny. Whilst there must be Response to John Gittins, HM Senior Coroner key

the right balance between staff welfare and patient safety, ultimately, the Trust must be able to effectively manage the resources available to it, taking into account clinical demands on the service, patient and staff safety and dynamically risk assessing this in real time A series of workplace policies are due to be presented to the Trust Board (beginning in March 2014) to be ratified s0 that changes in practice such as those described below can be implemented. At the time of the incident the practice was for crews who were travelling back to their base for their break not to be interrupted if were beyond 5-6 hours from start of their shift; The Trust is reviewing its meal break policy with the aim that staff in the future will take their break at the most appropriate place Whilst there is more work to be done this important policy is being discussed further by the Trust Board on 20 March 2014. The Trust recognises that the implementation of this policy is needed urgently. All the Heads of Service in the Trust have made arrangements with the respective Health Boards for staff to have their main breaks in the Hospitals and other NHS facilities and staff who work more than 10 hours are also able to take their supplementary breaks at those NHS facilities, rather than return to their base. Weare having discussions with Health Trusts in England to enable the same arrangements for staff to take breaks when taking patients to hospitals in England. The Trust has a Voluntary Availability and Disturbance Procedure (this was developed in 2008 as an addition to the Rest Break Policy) which operates in conjunction with the current Rest Break Policy and recognises the problems associated with providing cover for crews on their main, unpaid rest break and that some employees wish to make themselves available for calls during this unpaid break In this respect there are now increased opportunities for the Voluntary Availability and Disturbance Policy to be applied by Clinical Contact Centres (CCCs) to request staff to be available during their rest breaks in emergency circumstances, which is not call specific Crews are disturbed during their paid supplementary break for an emergency Red Call categorised as a Red 1 and Red 2. If the crew is disturbed during the first 15 minutes of their 30 minute supplementary rest break window will be allocated a further 15 minutes at the completion of their shift: There will be no recompense in time for any disturbance in the last 15 minutes of the period. The Trust has adopted an education programme for the control staff to promote the new policy and to ensure there is consistent approach in application across the Trust. This will be implemented when the new policy is formally approved. The BCU Health Board actively supports WAST crews to utilise its facilities in support of mandatory breaks. Details of facilities and availability in BCU are included within Appendix 1 Response to John Gittins, HM Senior Coroner they they they

3. That the current practices in place for the handover of patients at an Emergency Department far too often result in wholly unacceptable with patients being kept waiting for periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is multi-factorial problem, improvements must be made S0 as to reduce the risk of future deaths. We would Iike to take this opportunity to provide you with assurance that the Health Board and the Trust are committed to ensuring handover processes are in place that are safe and effective; and when there are circumstances of patients experiencing delays during handover steps are taken to ensure patients are properly monitored and that any changes in their condition are communicated and acted upon appropriately. The Health Board is taking all reasonable steps to improve "patient flow" within each community area and District General Hospital: of the pressures experienced in Emergency Departments (and by the Welsh Ambulance Service) are due to capacity within the community to respond to urgent clinical problems before become emergencies, and also maintaining an adequate of patients through and out of the hospital system SO our Emergency Departments do not get overcrowded. The issues which you have raised are vitally important and the Health Board is committed to working with the Ambulance Trust and other partners to improve the current situation as matter of urgency_ The BCUHB Medical Director has communicated these issues to all Clinical Leaders, Consultant Medical Staff and NHS Professional Managers across the Health Board, (Please see Appendices 2 & 3) 'Delivery Group has been commissioned by the Local Health Board comprising of Senior Managers from the two organisations to oversee developments within Unscheduled Care in North Wales_ The Group has various work streams to implement approaches which will improve flow and signpost patients to alternative pathways of care, as opposed to conveying to Emergency Departments by default: In line with the practice in the other Clinical Contact Centres, Advanced Paramedic Practitioners (APPs) are now working within the Clinical Contact Centres in order to enhance patient safety and to provide clinical advice to control based and operational WAST colleagues and also to patients and relatives who require our services The Group is considering extending the Consultant currently seconded in the North Clinical Contact Centre and also exploring the possibly of enhancing the facility through utilising extended hours. Specific ongoing work includes: Redefining border areas to equate the volume of WAST attendances at the three DGHs; Llandudno Hospital Minor Injuries (MIU) access criteria have been amended to allow more patients to be treated in this site as opposed to utilising Glan Clwyd or Ysbyty Gwynedd ED; The role of Llandudno MIU is strengthened with 2 WAST Trainee Advances Practitioners receiving mentorship from a BCU Consultant based in Llandudno MIU and will work one shift per week at the MIU but will be available to respond to any calls in the area; WAST and the Health Board are conducting more joint training for Silver On Call' managers from both organisations; Response to John Gittins, HM Senior Coroner delays long Many they flow being

Serious Adverse Incident Reviews will be conducted jointly if there are issues relative to both organisations; There are early discussions considering the feasibility and benefits for a North Wales Bed Bureau Since receiving your letter the Health Board has communicated the issues to the operational and clinical teams and worked with those clinical teams to improve the situation concerning delays in ED admission and the knock on impact on ambulance resources_ The Health Board's Medical Director has worked with the appropriate Chiefs of Staff and Departmental Heads aiming to improve patient flow and improved patient discharge arrangements (Please see Appendices 2 & 3). There has been communication with all senior medical staff to outline their roles and responsibilities in improving patient care with respect to ED review, admission and discharge. Meanwhile specific initiatives have been planned for implementation within the next 1-2 months_ (1) There will be monthly clinical audits performed to provide assurance regarding the safe management of patients who are delayed in Ambulances outside Emergency Departments prior to admission. The audits will facilitate the implementation of practice changes which improve patient flow_ The results of the audit will be presented to the Medical Director; Director of Nursing, Interim Chief Operating Officer, local Hospital Management Teams_ local Patient Safety Groups to ensure Health Board assurance. The audit tool is attached (Please see Appendix 4). (2) WAST and the Health Board have accelerated the discussion which was taking place relating to agreement and implementation of flow chart (Please see Appendix 5 (in draft)) to address the clinical risks_relating to patients waiting in Ambulances_ This is being further discussed at a meeting on Thursday 27 March 2014, There will be a focus on implementing the "Frailty Programme" to provide early supportive discharge across the Health Board. The Health Board has two teams taking part in the National Patient Flow Collaborative which has clear aims to make consistent and sustainable improvements to Unscheduled Care_ (3) WAST and the Health Board are working together with colleagues across Wales regarding completion of an All Wales Handover Policy which describes evidence based processes for patient handover between clinical teams_ We will forward this to you as soon as it is completed and agreed. (4) The Health Board attended the Royal College of Physicians (RCP) and proposed that it acts as a 'Demonstrator Site" to implement the RCPs "Future Hospitals Commission Report" that referred to many of the issues that result in overcrowding in Emergency Departments_ In conclusion We hope that this joint response from WAST and Health Board provides you with the assurances you require in response to content of your Regulation 28 letter dated 21 January Response to John Gittins, HM Senior Coroner the the

2014. Both organisations are committed to learn lessons from this difficult case and ensure that patient outcomes are improved with more effective clinical care without delays. The necessary improvements and changes are varied and cut across WAST and the Health Board's responsibilities as well as other organisations in North Wales. They are being implemented as quickly as possible and WAST and the Health Board will continue to monitor these actions as of their assurancelperformance management arrangements including Board level review_ Please contact us if any of this report of progress to date is unclear or if there are still areas of concern. We commit to keep you informed of progress with respect to the initiatives occurring in North Wales as well as those with an all Wales impact: Thank you once again for your letter regarding these important issues_