Welsh Ambulance Service NHS Trust
NHS / Health Body
Action Taken
The Trust has focused on actions to mitigate real time avoidable harm and has sustained reporting to their Trust Board on progress. Clinicians from the Clinical Support Desk review waiting calls and will speak directly to 999 callers and/or the patient to establish if other methods of response might be suitable, and to ensure the priority assigned to the call does not need to be adjusted. (AI summary)
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Dear Ms Saunders
Re: Mrs Dorothy Anne Jones
I write in response to the Prevention of Future Deaths Report issued to this Trust on 20 January 2023, following the inquest in relation to Dorothy Anne Jones.
You have asked the Trust to consider 4 specific areas:
1. The steps being undertaken on a national and local level to address the delays in ambulance response times, particularly within the Amber 1 category.
The Trust has focused on actions to mitigate real time avoidable harm and has sustained reporting to our Trust Board on progress. Attached is a copy of the progress report, with accompanying action plan, provided at the open Trust Board in January 2023. As recognised, the pressures are multifactorial but none as significant as those connected with patient flow leading to emergency department handover delays. These delays remain elevated with more than 32 thousand hours lost to extended handover in December 2023 amounting to 37% of our conveying resource capacity. In January 2023, this will be between 23-24 thousand hours which remains extremely high.
2 Whilst too early to indicate sustained improvement, as levels of activity abate (particularly that connected to respiratory illness) there has been improvement in the Amber 1 median response time in January 2023 compared to the proceeding period. The Trust will continue to report progress against the actions to mitigate avoidable harm to its Trust Board.
2. Whether consideration can be given to undertaking a more detailed clinical assessment of the patients within Amber 1 to ensure those in the greatest need for clinical intervention are given priority. To ensure that the Welsh Ambulance Services NHS Trust (WAST) maintains a clinically safe response to patients, regular reviews are undertaken of current Medical Priority Dispatch System (MPDS) code categorisation by the Clinical Priority Assessment Software (CPAS) group.
During reviews, each individual code is considered, in terms of the types of patients who should be within that category, as well as historical data on call volume, conveyance rates, adverse incidents, and where available, data on success rates of secondary triage, etc. The codes are also compared to the categorisation within the Ambulance Response Programme (ARP). These are the categorisations used by the Ambulance Services in England.
In the live environment, WAST regularly undertakes more detailed clinical assessments of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the correct priority for patients. This process, known as secondary triage or consultation is led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control room nurses, paramedics, advanced paramedics, and mental health practitioners.
The process of secondary triage or consultation involves clinicians assessing patients remotely using clinical decision support software over the phone or through video
3 consultation. WAST has recently invested in the CSD by near doubling its establishment, employing mental health practitioners, and by implementing a new innovative clinical decision support system to support the more detailed clinical assessment of patients.
WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.
3. The process for reassessment of the patient’s clinical condition during the time they are waiting for an ambulance.
The Clinical Safety Plan (CSP) provides a framework for the Trust to respond to situations where the demand for services is greater than the available resources. It recognises that causes can be multifaceted impacting either demand for services, the capacity to respond to demand, or both.
The CSP provides a set of tactical options that are flexible and immediate so that the Trust can dynamically react to situations to ensure those patients with the most serious conditions or in greatest need according to their presentation remain prioritised to receive services.
A copy of the CSP is attached for your reference and as you will see this provides details of when welfare calls should be made. These calls are made to reassess the patient’s clinical condition, if any changes are reported.
Additionally, the CSP provides details of the actions to be undertaken by the clinicians working on the Clinical Support Desk.
The CSP operates alongside the Clinical Support Desk Standard Operating Procedure (SOP), which also documents the actions to be taken by clinicians when there are long waits for patients. The SOP provides details of the action’s clinicians on the CSD can take with regard to upgrading the call.
4. Confirm whether the national algorithm adopted by WAST is fit for purpose and that there is provision to identify life-threatening scenarios, where a patient may quickly deteriorate from an Amber 1 into a Red. The Trust uses 5 priority categories for emergency calls. As per the evidence provided at the inquest, these are known as Red, Amber-1, Amber-2, Green-2, and Green-3. Whilst the terminology is different to other UK ambulance services (For example, English services use 5 priority categories, known as Category 1 through to Category 5), but the principles of prioritisation, and the vast majority of calls within each category are similar across other UK services.
The utilisation of the Trust’s resources is undertaken in line with our Clinical Response Model. Within that model calls are generally responded to chronologically, within their priority category. So, it is broadly accurate to say that, for example, Amber-1 calls waiting for a response are generally responded to in chronological order within the priority, as
4 based on available information from the 999 calls. Again, this is in keeping with the principles used by all other UK ambulance services.
The staff responsible for the allocation of the resources can allocate resources out of chronological order and this is documented in the attached Standard Operating Procedure - Action Cards for Emergency Medical Dispatch.
However, when the Trust is unable to respond as quickly as we would like to be able to, waiting 999 calls (in all priorities/categories) are subject to clinical scrutiny by the Clinical Support Desk (CSD).
Clinicians from the Clinical Support Desk review waiting calls and will speak directly to 999 callers and/or the patient to establish if other methods of response might be suitable, and to ensure the priority assigned to the call does not need to be adjusted. These clinicians can change the priority of any 999 call, increasing it or decreasing it, according to the outcome of their more detailed clinical triage.
Whilst writing I would like to extend my sincere condolences to Mrs Jones’ family on their sad loss. I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continual improvement to support the prevention of future deaths.
Re: Mrs Dorothy Anne Jones
I write in response to the Prevention of Future Deaths Report issued to this Trust on 20 January 2023, following the inquest in relation to Dorothy Anne Jones.
You have asked the Trust to consider 4 specific areas:
1. The steps being undertaken on a national and local level to address the delays in ambulance response times, particularly within the Amber 1 category.
The Trust has focused on actions to mitigate real time avoidable harm and has sustained reporting to our Trust Board on progress. Attached is a copy of the progress report, with accompanying action plan, provided at the open Trust Board in January 2023. As recognised, the pressures are multifactorial but none as significant as those connected with patient flow leading to emergency department handover delays. These delays remain elevated with more than 32 thousand hours lost to extended handover in December 2023 amounting to 37% of our conveying resource capacity. In January 2023, this will be between 23-24 thousand hours which remains extremely high.
2 Whilst too early to indicate sustained improvement, as levels of activity abate (particularly that connected to respiratory illness) there has been improvement in the Amber 1 median response time in January 2023 compared to the proceeding period. The Trust will continue to report progress against the actions to mitigate avoidable harm to its Trust Board.
2. Whether consideration can be given to undertaking a more detailed clinical assessment of the patients within Amber 1 to ensure those in the greatest need for clinical intervention are given priority. To ensure that the Welsh Ambulance Services NHS Trust (WAST) maintains a clinically safe response to patients, regular reviews are undertaken of current Medical Priority Dispatch System (MPDS) code categorisation by the Clinical Priority Assessment Software (CPAS) group.
During reviews, each individual code is considered, in terms of the types of patients who should be within that category, as well as historical data on call volume, conveyance rates, adverse incidents, and where available, data on success rates of secondary triage, etc. The codes are also compared to the categorisation within the Ambulance Response Programme (ARP). These are the categorisations used by the Ambulance Services in England.
In the live environment, WAST regularly undertakes more detailed clinical assessments of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the correct priority for patients. This process, known as secondary triage or consultation is led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control room nurses, paramedics, advanced paramedics, and mental health practitioners.
The process of secondary triage or consultation involves clinicians assessing patients remotely using clinical decision support software over the phone or through video
3 consultation. WAST has recently invested in the CSD by near doubling its establishment, employing mental health practitioners, and by implementing a new innovative clinical decision support system to support the more detailed clinical assessment of patients.
WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.
3. The process for reassessment of the patient’s clinical condition during the time they are waiting for an ambulance.
The Clinical Safety Plan (CSP) provides a framework for the Trust to respond to situations where the demand for services is greater than the available resources. It recognises that causes can be multifaceted impacting either demand for services, the capacity to respond to demand, or both.
The CSP provides a set of tactical options that are flexible and immediate so that the Trust can dynamically react to situations to ensure those patients with the most serious conditions or in greatest need according to their presentation remain prioritised to receive services.
A copy of the CSP is attached for your reference and as you will see this provides details of when welfare calls should be made. These calls are made to reassess the patient’s clinical condition, if any changes are reported.
Additionally, the CSP provides details of the actions to be undertaken by the clinicians working on the Clinical Support Desk.
The CSP operates alongside the Clinical Support Desk Standard Operating Procedure (SOP), which also documents the actions to be taken by clinicians when there are long waits for patients. The SOP provides details of the action’s clinicians on the CSD can take with regard to upgrading the call.
4. Confirm whether the national algorithm adopted by WAST is fit for purpose and that there is provision to identify life-threatening scenarios, where a patient may quickly deteriorate from an Amber 1 into a Red. The Trust uses 5 priority categories for emergency calls. As per the evidence provided at the inquest, these are known as Red, Amber-1, Amber-2, Green-2, and Green-3. Whilst the terminology is different to other UK ambulance services (For example, English services use 5 priority categories, known as Category 1 through to Category 5), but the principles of prioritisation, and the vast majority of calls within each category are similar across other UK services.
The utilisation of the Trust’s resources is undertaken in line with our Clinical Response Model. Within that model calls are generally responded to chronologically, within their priority category. So, it is broadly accurate to say that, for example, Amber-1 calls waiting for a response are generally responded to in chronological order within the priority, as
4 based on available information from the 999 calls. Again, this is in keeping with the principles used by all other UK ambulance services.
The staff responsible for the allocation of the resources can allocate resources out of chronological order and this is documented in the attached Standard Operating Procedure - Action Cards for Emergency Medical Dispatch.
However, when the Trust is unable to respond as quickly as we would like to be able to, waiting 999 calls (in all priorities/categories) are subject to clinical scrutiny by the Clinical Support Desk (CSD).
Clinicians from the Clinical Support Desk review waiting calls and will speak directly to 999 callers and/or the patient to establish if other methods of response might be suitable, and to ensure the priority assigned to the call does not need to be adjusted. These clinicians can change the priority of any 999 call, increasing it or decreasing it, according to the outcome of their more detailed clinical triage.
Whilst writing I would like to extend my sincere condolences to Mrs Jones’ family on their sad loss. I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continual improvement to support the prevention of future deaths.