Cardiff and Vale University Health Board
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[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The HM Coroner, for the Coroner Area South Wales (Central) in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Alan Rees
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, the Cabinet Minister for Health and Care provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 23 September 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: During the course of the inquest, the Coroner heard evidence from emergency medical and nursing staff that, despite efforts made since Mr Rees’ death in 2022, emergency department overcapacity, workforce pressures and exit block remain significant challenges. The Coroner was advised that staffing establishments are based on expected patient numbers that are substantially lower than actual demand and heard evidence that workforce constraints within the emergency department are now broadly similar to those experienced at the time of Mr Rees’ death. The Coroner also heard that patient attendances have continued to increase year-on-year and, although a range of improvement measures have been implemented by the health board, these have not provided sufficient assurance that the risks associated with overcrowding, insufficient staffing and exit block have been adequately mitigated. The Coroner expressed concern that these factors continue to contribute to delays in treatment and patient harm. The Coroner further raised concerns that the persistence of these pressures across the NHS may have led to a culture of acceptance of overcrowding
[Page 2] and workforce constraints, with a risk that more fundamental changes required to improve patient safety are not being implemented at the pace necessary to prevent future deaths. The Coroner therefore seeks assurance regarding the collaborative action being taken by Welsh Government and Cardiff and Vale University Health Board to address emergency department overcapacity, workforce pressures and exit block, and to ensure the timely and safe delivery of care to patients.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. The Welsh Government does not consider emergency department overcrowding, corridor care, prolonged ambulance handover delays or avoidable exit block to be acceptable or inevitable features of urgent and emergency care. Health boards are expected to identify, report and escalate risks to patient safety arising from crowding and capacity pressures, and to take timely corrective action through local operational arrangements. Through national performance, escalation and accountability arrangements, Welsh Government will continue to seek assurance that risks are visible, actively managed and not normalised, and that improvement plans include clear actions, timescales, accountable leads and measurable outcomes. National expectations for urgent and emergency care The NHS Wales Planning Framework requires health boards to deliver the principles set out in national urgent and emergency care frameworks. These include: -
• implementation of single points of access so people with urgent care needs receive timely and appropriate support;
• a focus on prevention and early intervention;
• tailored pathways for frail and older people;
• urgent community response; and
• stronger integration with the Welsh Ambulance Services University NHS Trust and local authorities. Health boards are also held to clear expectations on ambulance handovers and emergency department waiting times. The immediate national priorities are to eliminate ambulance handovers exceeding 45 minutes and reduce the number of people waiting more than 12 hours in emergency care settings. Dedicated support is provided for local improvement and recovery plans, with delivery and impact subject to national oversight. Welsh Government continues to invest significantly in urgent and emergency care and hospital discharge improvement through a range of complementary funding streams. In 2026/27, this includes over £23 million through the Urgent
[Page 3] and Emergency Care Improvement Programme to support delivery of national priorities and service improvement, £146 million through the Regional Integration Fund to strengthen integrated health and social care services and reduce avoidable hospital admissions, and £30 million through the Pathways of Care Transformation Grant to expand community-based support, improve patient flow and reduce delays in hospital discharge. Improving patient flow and discharge The Welsh Government expects health boards to identify, report and escalate unsafe crowding and corridor care, rather than normalise it. National and local improvement work is directed at the underlying causes of crowding rather than the emergency department in isolation. This includes reducing avoidable admission, strengthening same-day emergency care and direct admission pathways, improving early senior clinical decision-making, increasing the use of community alternatives, and supporting discharge without delay. These measures are intended to release acute capacity, reduce long waits and enable staff to provide care in an appropriate clinical environment. Enabling better flow through an Integrated Community Care System The Integrated Community Care System blueprint provides the national framework for delivering integrated health and care, supporting the shift from reactive, hospital-based care to services closer to home, coordinated and delivered through Regional Partnership Boards. The £30 million Pathways of Care transformation grant to local authorities is supporting these improvements by expanding community and intermediate care services that enable people to leave hospital more quickly and safely, while also strengthening preventative and early intervention approaches that reduce avoidable admissions through earlier intervention with more proactive community support and help people remain well at home. I expect all regions to demonstrate measurable progress through their urgent and emergency care improvement plans and operational delivery arrangements. NHS Wales Performance and Improvement (NHS-WPI) and the National Office of Care and Support are supporting and challenging organisations on patient flow and discharge productivity, with a focus on the most pressured parts of the system. Oversight, assurance and improvement support The Welsh Government’s arrangements for supporting, assuring and holding NHS Wales organisations to account for the delivery of national policy priorities are delivered in part through NHS-WPI. NHS-WPI is a national support function that works with the NHS in Wales to deliver better health services and outcomes for patients and the public, and to support the Welsh Government in holding NHS Wales organisations to account for the delivery and performance of these services and for robust financial management,
[Page 4] including through, the national Urgent and Emergency Care Programme team and other NHS-WPI directorates. NHS-WPI supports Welsh Government's accountability arrangements by monitoring the performance of NHS Wales organisations by sharing regular updates with Welsh Government and escalating issues as appropriate, providing financial delivery support and providing performance management and planning advice. In particular, NHS-WPI plays a key role in monitoring progress against key flow-related enabling actions, including increasing discharges before midday and supporting delivery of the Optimal Hospital Flow Framework (OHFF). NHS-WPI has also been instructed by Welsh Government to closely monitor and seek assurance on key performance indicators including ambulance patient handover delays, stays of longer than 12-hours in emergency departments before admission or discharge, clinically optimised patients, and discharge delays. These data are monitored daily by NHS-WPI through national executive-level emergency care pressures calls, and monthly through performance management mechanisms. NHS-WPI’s role is however supportive and facilitative to the Welsh Ministers’ oversight of the NHS in Wales and responsibility for the strategic direction, oversight and accountability of the NHS in Wales ultimately remains with the Welsh Ministers. Workforce While responsibility for ensuring staffing levels are appropriate to local service demand rests with individual health boards and trusts, the Welsh Government recognises the importance of maintaining a sustainable workforce across NHS Wales. Through sustained investment in education and training, the Welsh Government is strengthening the pipeline of healthcare professionals entering the workforce and supporting measures to improve recruitment and retention. These measures form part of our wider approach to strengthening workforce capacity across NHS Wales, recognising the challenges arising from increasing demand and service pressures. Escalation and response In July 2025, Cardiff and Vale University Health Board (CVUHB) escalated to Level 4 under the NHS Wales Oversight and Escalation Framework following an assessment of concerns, including an increasing financial deficit, quality concerns, planned care waiting times, as well as organisational culture and leadership. Level 4 is the second-highest level of escalation and provides for coordinated action, direct intervention and external support where there are serious concerns that an organisation cannot deliver the necessary improvements at the required pace without additional assistance. The targeted intervention approach at CVUHB is split in two parts, for Phase 1, Welsh Government, with the support of NHS-WPI and in alignment with the
[Page 5] leadership of the health board arranged an independent review against the areas of escalation concern and its proposed actions to understand and advise all parties on the underlying causes of the areas of escalation and challenge, with a specific focus on governance, organisational culture and leadership, a view on the validity and likely efficacy of the established improvement plans, as well as an outline of the approach to a Phase 2 intervention programme. Following the review in June 2026, on 7 August 2026, NHS-WPI published the independent assessors report that identified systemic and longstanding challenges across leadership, culture, governance, planning, risk management, clinical governance, digital maturity and organisational capability. CVUHB continue to be supported by NHS-WPI to identify and agree the requirements of the Phase 2 intervention, before agreement by the Welsh Government. CVUHB response to the intervention work will include a single organisation-wide improvement plan, with clear actions, accountability, milestones and measurable outcomes. Delivery will continue to be monitored through the established escalation and accountability arrangements, with further intervention available if improvement is not demonstrated at the scale or pace required. CVUHB has received a copy of the report and is best placed to set out the specific operational action taken within the University Hospital of Wales Emergency Department, including any changes to staffing, capacity, escalation, medication administration, patient flow and risk management.
5. DETAILS OF FURTHER ACTION PROPOSED Ongoing monitoring and evaluation Welsh Government, supported by NHS-WPI, will continue to monitor delivery against national expectations for ambulance handover, emergency department waits, patient flow and discharge. Performance review and accountability arrangements will be used to test whether actions are producing sustained improvement, with risks escalated where progress is insufficient. Reducing avoidable demand and conveyance The Welsh Government is supporting the development of local, community- based models of care through the Community by Design programme, helping more people access the right care closer to home and avoiding emergency department attendance and hospital admission wherever clinically appropriate. The programme seeks to shift the focus of the health and care system towards prevention, early intervention and proactive support, helping
[Page 6] people maintain their health and independence within their communities. It is intended to bring services together across organisational boundaries and strengthen prevention, long-term condition management, urgent community support and multidisciplinary working closer to people’s homes. Emergency and Acute Care Policy Framework to 2030 The Welsh Government is developing a new Emergency and Acute Care Policy Framework to 2030, planned for publication in November 2026. It will set a clearer national direction for improving outcomes, experience and timely access for people with the most serious and complex emergency and acute care needs. The framework will adopt a whole-system, pathway-based approach, focusing on rapid response, time-critical care, acute hospital services, patient flow and safe discharge. It will support targeted action to reduce delays in assessment, treatment and discharge, optimise the use of available capacity, and minimise the risk of care being delivered in inappropriate settings. The development of the Framework reflects a strengthened national focus on patient flow, recognising that sustainable improvements in emergency care depend on effective movement through the entire pathway, from rapid access and assessment through to timely discharge. The Framework is being informed by extensive engagement with health boards, NHS Wales organisations, local government, professional bodies, clinical leaders, third sector partners and people with lived experience, including the Royal College of Emergency Medicine (RCEM), ensuring that both operational experience and expert clinical perspectives are reflected in its development. NHS Wales Corridor Care Action Group The Cabinet Minister for Health and Care established the NHS Wales Corridor Care Action Group as part of the Welsh Government’s wider programme of work to reduce and ultimately eliminate corridor care in Wales, the first meeting took place on the 3 September 2026. The Group has been commissioned to develop a consistent all-Wales approach to defining, measuring and reporting corridor care, recognising the risks it poses to patients, families and staff. The Action Group is chaired by the NHS Wales Director of Operations within the Health Care and Prevention Group, Welsh Government, and brings together representatives from NHS Wales organisations, professional bodies, patient and public advocacy organisations, data and improvement experts, social care partners and Welsh Government policy leads. The Group has been established to develop recommendations on a nationally agreed definition of corridor care, minimum safety and quality safeguards, consistent reporting arrangements, and appropriate governance and escalation processes. Its work is intended to strengthen national transparency,
[Page 7] consistency and accountability, supporting NHS Wales organisations to better identify, monitor and respond to corridor care. The Action Group is advisory in nature and reports to the Cabinet Minister for Health and Care through Welsh Government executive leadership arrangements. It is meeting on a fortnightly basis to develop recommendations at pace, culminating in a final report for ministerial consideration. Its work will inform wider urgent and emergency care improvement activity, alongside ongoing action across NHS Wales to improve patient flow, reduce delays and strengthen alternatives to hospital admission. Welsh Government considers the establishment of the Action Group an important step in strengthening national oversight and accountability in relation to corridor care, while supporting broader system-wide action to improve patient experience, quality and safety across NHS Wales. Collaboration with CVUHB Welsh Government will continue to work with CVUHB through the established performance and accountability arrangements to seek assurance that local action addresses the interaction between staffing, physical capacity and exit block, and that improvement is reflected in safer and more timely care. It is understood that CVUHB will provide the Coroner with its own account of local actions and timescales.
6. SIGNATURE Gweinidog Cabinet dros Iechyd a Gofal Cabinet Minister for Health and Care
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, the Cabinet Minister for Health and Care provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 23 September 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: During the course of the inquest, the Coroner heard evidence from emergency medical and nursing staff that, despite efforts made since Mr Rees’ death in 2022, emergency department overcapacity, workforce pressures and exit block remain significant challenges. The Coroner was advised that staffing establishments are based on expected patient numbers that are substantially lower than actual demand and heard evidence that workforce constraints within the emergency department are now broadly similar to those experienced at the time of Mr Rees’ death. The Coroner also heard that patient attendances have continued to increase year-on-year and, although a range of improvement measures have been implemented by the health board, these have not provided sufficient assurance that the risks associated with overcrowding, insufficient staffing and exit block have been adequately mitigated. The Coroner expressed concern that these factors continue to contribute to delays in treatment and patient harm. The Coroner further raised concerns that the persistence of these pressures across the NHS may have led to a culture of acceptance of overcrowding
[Page 2] and workforce constraints, with a risk that more fundamental changes required to improve patient safety are not being implemented at the pace necessary to prevent future deaths. The Coroner therefore seeks assurance regarding the collaborative action being taken by Welsh Government and Cardiff and Vale University Health Board to address emergency department overcapacity, workforce pressures and exit block, and to ensure the timely and safe delivery of care to patients.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. The Welsh Government does not consider emergency department overcrowding, corridor care, prolonged ambulance handover delays or avoidable exit block to be acceptable or inevitable features of urgent and emergency care. Health boards are expected to identify, report and escalate risks to patient safety arising from crowding and capacity pressures, and to take timely corrective action through local operational arrangements. Through national performance, escalation and accountability arrangements, Welsh Government will continue to seek assurance that risks are visible, actively managed and not normalised, and that improvement plans include clear actions, timescales, accountable leads and measurable outcomes. National expectations for urgent and emergency care The NHS Wales Planning Framework requires health boards to deliver the principles set out in national urgent and emergency care frameworks. These include: -
• implementation of single points of access so people with urgent care needs receive timely and appropriate support;
• a focus on prevention and early intervention;
• tailored pathways for frail and older people;
• urgent community response; and
• stronger integration with the Welsh Ambulance Services University NHS Trust and local authorities. Health boards are also held to clear expectations on ambulance handovers and emergency department waiting times. The immediate national priorities are to eliminate ambulance handovers exceeding 45 minutes and reduce the number of people waiting more than 12 hours in emergency care settings. Dedicated support is provided for local improvement and recovery plans, with delivery and impact subject to national oversight. Welsh Government continues to invest significantly in urgent and emergency care and hospital discharge improvement through a range of complementary funding streams. In 2026/27, this includes over £23 million through the Urgent
[Page 3] and Emergency Care Improvement Programme to support delivery of national priorities and service improvement, £146 million through the Regional Integration Fund to strengthen integrated health and social care services and reduce avoidable hospital admissions, and £30 million through the Pathways of Care Transformation Grant to expand community-based support, improve patient flow and reduce delays in hospital discharge. Improving patient flow and discharge The Welsh Government expects health boards to identify, report and escalate unsafe crowding and corridor care, rather than normalise it. National and local improvement work is directed at the underlying causes of crowding rather than the emergency department in isolation. This includes reducing avoidable admission, strengthening same-day emergency care and direct admission pathways, improving early senior clinical decision-making, increasing the use of community alternatives, and supporting discharge without delay. These measures are intended to release acute capacity, reduce long waits and enable staff to provide care in an appropriate clinical environment. Enabling better flow through an Integrated Community Care System The Integrated Community Care System blueprint provides the national framework for delivering integrated health and care, supporting the shift from reactive, hospital-based care to services closer to home, coordinated and delivered through Regional Partnership Boards. The £30 million Pathways of Care transformation grant to local authorities is supporting these improvements by expanding community and intermediate care services that enable people to leave hospital more quickly and safely, while also strengthening preventative and early intervention approaches that reduce avoidable admissions through earlier intervention with more proactive community support and help people remain well at home. I expect all regions to demonstrate measurable progress through their urgent and emergency care improvement plans and operational delivery arrangements. NHS Wales Performance and Improvement (NHS-WPI) and the National Office of Care and Support are supporting and challenging organisations on patient flow and discharge productivity, with a focus on the most pressured parts of the system. Oversight, assurance and improvement support The Welsh Government’s arrangements for supporting, assuring and holding NHS Wales organisations to account for the delivery of national policy priorities are delivered in part through NHS-WPI. NHS-WPI is a national support function that works with the NHS in Wales to deliver better health services and outcomes for patients and the public, and to support the Welsh Government in holding NHS Wales organisations to account for the delivery and performance of these services and for robust financial management,
[Page 4] including through, the national Urgent and Emergency Care Programme team and other NHS-WPI directorates. NHS-WPI supports Welsh Government's accountability arrangements by monitoring the performance of NHS Wales organisations by sharing regular updates with Welsh Government and escalating issues as appropriate, providing financial delivery support and providing performance management and planning advice. In particular, NHS-WPI plays a key role in monitoring progress against key flow-related enabling actions, including increasing discharges before midday and supporting delivery of the Optimal Hospital Flow Framework (OHFF). NHS-WPI has also been instructed by Welsh Government to closely monitor and seek assurance on key performance indicators including ambulance patient handover delays, stays of longer than 12-hours in emergency departments before admission or discharge, clinically optimised patients, and discharge delays. These data are monitored daily by NHS-WPI through national executive-level emergency care pressures calls, and monthly through performance management mechanisms. NHS-WPI’s role is however supportive and facilitative to the Welsh Ministers’ oversight of the NHS in Wales and responsibility for the strategic direction, oversight and accountability of the NHS in Wales ultimately remains with the Welsh Ministers. Workforce While responsibility for ensuring staffing levels are appropriate to local service demand rests with individual health boards and trusts, the Welsh Government recognises the importance of maintaining a sustainable workforce across NHS Wales. Through sustained investment in education and training, the Welsh Government is strengthening the pipeline of healthcare professionals entering the workforce and supporting measures to improve recruitment and retention. These measures form part of our wider approach to strengthening workforce capacity across NHS Wales, recognising the challenges arising from increasing demand and service pressures. Escalation and response In July 2025, Cardiff and Vale University Health Board (CVUHB) escalated to Level 4 under the NHS Wales Oversight and Escalation Framework following an assessment of concerns, including an increasing financial deficit, quality concerns, planned care waiting times, as well as organisational culture and leadership. Level 4 is the second-highest level of escalation and provides for coordinated action, direct intervention and external support where there are serious concerns that an organisation cannot deliver the necessary improvements at the required pace without additional assistance. The targeted intervention approach at CVUHB is split in two parts, for Phase 1, Welsh Government, with the support of NHS-WPI and in alignment with the
[Page 5] leadership of the health board arranged an independent review against the areas of escalation concern and its proposed actions to understand and advise all parties on the underlying causes of the areas of escalation and challenge, with a specific focus on governance, organisational culture and leadership, a view on the validity and likely efficacy of the established improvement plans, as well as an outline of the approach to a Phase 2 intervention programme. Following the review in June 2026, on 7 August 2026, NHS-WPI published the independent assessors report that identified systemic and longstanding challenges across leadership, culture, governance, planning, risk management, clinical governance, digital maturity and organisational capability. CVUHB continue to be supported by NHS-WPI to identify and agree the requirements of the Phase 2 intervention, before agreement by the Welsh Government. CVUHB response to the intervention work will include a single organisation-wide improvement plan, with clear actions, accountability, milestones and measurable outcomes. Delivery will continue to be monitored through the established escalation and accountability arrangements, with further intervention available if improvement is not demonstrated at the scale or pace required. CVUHB has received a copy of the report and is best placed to set out the specific operational action taken within the University Hospital of Wales Emergency Department, including any changes to staffing, capacity, escalation, medication administration, patient flow and risk management.
5. DETAILS OF FURTHER ACTION PROPOSED Ongoing monitoring and evaluation Welsh Government, supported by NHS-WPI, will continue to monitor delivery against national expectations for ambulance handover, emergency department waits, patient flow and discharge. Performance review and accountability arrangements will be used to test whether actions are producing sustained improvement, with risks escalated where progress is insufficient. Reducing avoidable demand and conveyance The Welsh Government is supporting the development of local, community- based models of care through the Community by Design programme, helping more people access the right care closer to home and avoiding emergency department attendance and hospital admission wherever clinically appropriate. The programme seeks to shift the focus of the health and care system towards prevention, early intervention and proactive support, helping
[Page 6] people maintain their health and independence within their communities. It is intended to bring services together across organisational boundaries and strengthen prevention, long-term condition management, urgent community support and multidisciplinary working closer to people’s homes. Emergency and Acute Care Policy Framework to 2030 The Welsh Government is developing a new Emergency and Acute Care Policy Framework to 2030, planned for publication in November 2026. It will set a clearer national direction for improving outcomes, experience and timely access for people with the most serious and complex emergency and acute care needs. The framework will adopt a whole-system, pathway-based approach, focusing on rapid response, time-critical care, acute hospital services, patient flow and safe discharge. It will support targeted action to reduce delays in assessment, treatment and discharge, optimise the use of available capacity, and minimise the risk of care being delivered in inappropriate settings. The development of the Framework reflects a strengthened national focus on patient flow, recognising that sustainable improvements in emergency care depend on effective movement through the entire pathway, from rapid access and assessment through to timely discharge. The Framework is being informed by extensive engagement with health boards, NHS Wales organisations, local government, professional bodies, clinical leaders, third sector partners and people with lived experience, including the Royal College of Emergency Medicine (RCEM), ensuring that both operational experience and expert clinical perspectives are reflected in its development. NHS Wales Corridor Care Action Group The Cabinet Minister for Health and Care established the NHS Wales Corridor Care Action Group as part of the Welsh Government’s wider programme of work to reduce and ultimately eliminate corridor care in Wales, the first meeting took place on the 3 September 2026. The Group has been commissioned to develop a consistent all-Wales approach to defining, measuring and reporting corridor care, recognising the risks it poses to patients, families and staff. The Action Group is chaired by the NHS Wales Director of Operations within the Health Care and Prevention Group, Welsh Government, and brings together representatives from NHS Wales organisations, professional bodies, patient and public advocacy organisations, data and improvement experts, social care partners and Welsh Government policy leads. The Group has been established to develop recommendations on a nationally agreed definition of corridor care, minimum safety and quality safeguards, consistent reporting arrangements, and appropriate governance and escalation processes. Its work is intended to strengthen national transparency,
[Page 7] consistency and accountability, supporting NHS Wales organisations to better identify, monitor and respond to corridor care. The Action Group is advisory in nature and reports to the Cabinet Minister for Health and Care through Welsh Government executive leadership arrangements. It is meeting on a fortnightly basis to develop recommendations at pace, culminating in a final report for ministerial consideration. Its work will inform wider urgent and emergency care improvement activity, alongside ongoing action across NHS Wales to improve patient flow, reduce delays and strengthen alternatives to hospital admission. Welsh Government considers the establishment of the Action Group an important step in strengthening national oversight and accountability in relation to corridor care, while supporting broader system-wide action to improve patient experience, quality and safety across NHS Wales. Collaboration with CVUHB Welsh Government will continue to work with CVUHB through the established performance and accountability arrangements to seek assurance that local action addresses the interaction between staffing, physical capacity and exit block, and that improvement is reflected in safer and more timely care. It is understood that CVUHB will provide the Coroner with its own account of local actions and timescales.
6. SIGNATURE Gweinidog Cabinet dros Iechyd a Gofal Cabinet Minister for Health and Care