Present:
- Prof I Cumming*
Chairman
Non-Executive Director (Chairman) - Mr A C Marsh*
CEO
Chief Executive Officer - Prof. A Hopkins
AH
Non-Executive Director (Deputy Chair) - Mrs S Banks*
SB
Non-Executive Director - Ms C Beechey*
CB
Director of People - Mr A Brown
AB
Transformation & Patient Safety Director - Mrs C Eyre*
CE
Director of Nursing - Mr N Hudson
NH
Chief Operation Officer - Mrs J Jasper*
JJ
Non-Executive Director - Mr V Khashu
VK
Strategy & Engagement Director - Mr M MacGregor
MM
Communications Director - Mr S Nat*
SN
Non-Executive Director - Mrs K Rutter*
KR
Director of Finance - Dr R Steyn*
RS
Medical Director
* Denotes a voting member appointed pursuant to the Constitution of the West Midlands Ambulance Service NHS Foundation Trust
In attendance:
- Mr P. Higgins
PH – Governance Director & Trust Secretary - Mrs R Farrington
RF – Staff Side Representative - Ms K Freeman
KAF – Private Secretary - Mrs P Wall
PW – Head of Strategic Planning / FTSU Guardian - Mr I Syme
IS – Member of the Public - Ms C Tilley
CT – HSJ
05/26/01 Welcome, Apologies and Chairman’s Matters
Given that Eid fell on the same day as the Board meeting, apologies for absence were received from Mr Mohammed Fessall and Mr Mushtaq Khan.
05/26/02 Declarations of Interest
None declared in relation to any matters on the agenda for this meeting.
The Chairman reminded directors of their statutory duty in relation to conflicts and asked members of the Board to ensure their declarations in the register of interests is maintained and up to date as it is published on the Trust’s website.
- That the Register of Directors Interests be received
- That the Register of Governors Interests be received.
05/26/03 Questions Received from the Public Prior to the Meeting
None received.
05/26/04 Minutes
The Board was requested to approve the minutes of the meeting of the Board of Directors held on 25 March 2026 as an accurate record.
Pursuant to Minute Number 03/26/03 of the above Minutes and attached as paper 02a is the question and the response as an appendix to the minutes.
Resolved:
That the minutes of the meeting of the Board of Directors held on 25 March 2026 be approved as a correct record of that meeting.
That the question submitted and the response attached thereto as an appendix to the Minutes, be received.
05/26/05 Action Log and any Matters Arising not on the agenda for this meeting
a. The Board Log
The Board Action Log was submitted; the Action Log contains the schedule of matters upon which the Board have asked for further action or information to be submitted. Matters on this log can only be deleted through resolution of the Board. (For the avoidance of doubt unless specified below all matters contained on the Board log will remain on the log until the Board resolves that the matter can be discharged).
Minute 01/26/08b & 03/26/05 Manchester Arena Inquiry (MAI) Recommendations & Needs Analysis Register
Given the risks to the public in the absence of funding to apply the WMAS Needs Analysis based on the MAI recommendations. The Chairman asked the Board to keep this matter on the Action Log for a further update.
The CEO had raised his concerns again with NHS England (NHSE). He stated that a paper had been presented to the NHSE Executive Board at the end of April 2026 where they had noted and accepted the risks and agreed that it would take action to ensure Ambulance Services were properly funded to implement the recommendations arising out of the public inquiry.
He reminded the Board meeting that the recommendations arising from the inquiry into this tragic incident which concluded over 3 years previously.
The CEO stated that there was to be a subsequent paper which is due to be submitted to the NHSE Executive Board at the end of June 2026 and the Trust was awaiting to see how much of its bid of £32m of additional funding to fulfill all the recommendations based on the Trusts own needs assessment.
The CEO will keep the Board updated.
The Board agreed to keep this matter on the Action Log for a further update by the CEO to the next Board meeting.
Minute 03/26/06 Board Assurance Framework (BAF)
During the discussion at the last meeting on the Board Assurance Framework the Chairman asked Karen Rutter and Mohammed Fessal to lead on the Board Briefing session with input from across the organization utilizing the June and September Board Briefing sessions.
The Board was advised that at its Briefing in June 2026 the Board will receive a presentation from a representative of the National Cyber Security Centre on Cyber Security Governance and the role of the Board, the SIRO, and directors.
The Board Briefing in September 2026 will receive a presentation on development and opportunities of AI for healthcare led by Mohammed Fessal.
It was agreed that this matter would remain on the Action Log until the sessions were complete.
03/26/07d 1. Provider Capability Assessment outcome
2. Quarterly Segmentation Outcome
The CEO had reported at the meeting in March 2026 that in terms of the Provider Capability Assessment the Trust has been rated as Green Amber and NHSE has undertaken to let us know what the Trust needs to do to get too Green.
In relation to the Quarterly Segmentation Report, the Trust has been rated as segment 3. The CEO indicated that the Trust has sought clarity from the NHSE on the reasoning, but nothing had been received to date.
The request for additional information underpinning the reasons for the ratings was made back in February and still there had been no response.
The NHSE convened Performance Review Meeting, which has an outstanding action for the NHSE to provide the clarity was postponed by the NHSE earlier that month by the NHSE at very short notice.
The Chairman indicated that unless the Trust is provided with specifics underpinning the reasons for the outcome ratings by the NHSE then it cannot take the appropriate action.
The Chairman asked the CEO to pursue the NHSE for a response.
It was agreed that this matter will remain on the action log for an update at the next meeting.
05/26/06 Board Assurance Framework
The Board Assurance Framework was submitted for Board review by the Director of Nursing.
In presenting the report the Director of Nursing who was attending via Microsoft Teams experienced technical problems addressing the Board so the Chairman asked the Director of Nursing to reboot and rejoin the meeting.
Given this he asked the CEO to continue with his item and that the Board would return to the BAF later in the meeting when the Director of Nursing was able to “attend” and introduce the item.
On this basis the Board of Directors agreed to vary the agenda items.
See Minute 05/26/09 below.
05/26/07 Chief Executive Officer Reports
a. The CEO Report
A report of the CEO was submitted. The CEO highlighted the following salient matters from the report.
The Trust has implemented the revised Pandemic Plan and sets out how the Trust will respond to a pandemic.
Work continues to take forward the collaborative work with East Midlands Ambulance Service (EMAS). Joint workstreams are being developed and the most notable is the creation of a joint Head of IT for both Trusts.
In the summer we will bring forward the joint working plans for the next 3 months. The first meeting of the Programme Board is scheduled for tomorrow and Mohammed Fessal is the WMAS NED on the programme Board.
An update will be submitted to the next Board Meeting.
The Trust is contributing through the Association of Ambulance Chief Executives organisation to the Health Bill currently making its way through Parliament.
Resolved:
That the report be received and noted.
That retrospective approval be given to the publication of the revised Pandemic Plan.
b. Performance Scorecards
1. Executive Scorecard – March & April 2026
2. Executive Scorecard ICS Sub Report – March & April 2026
The Executive Scorecards were submitted.
The CEO indicated that the content receives more detailed review by the Finance & Performance Committee.
Resolved:
That the Executive Scorecards submitted be received and noted.
c. Trust’s Five-Year Strategy – Update
A report of the Strategy and Engagement Director was submitted.
The Strategy and Engagement Director updated the Board of Directors (BoD) on the development of the Trust’s Draft Strategy 2026-2031.
Feedback had been received following the Board meeting in March 2026. Non-Executive Directors, Julie Jasper, and Suzanne Banks have also reviewed the draft and provided comments on the content.
The Director of Nursing had felt that the Trust’s Strategy should set out the Trust’s vision to deliver against Neighbourhood Health strategy.
This was a major operational transformation of the NHS and local government that shifts care from hospitals into local communities.
Neighbourhood Health aims to bring together GPs, district nurses, social workers, and mental health teams into integrated multidisciplinary teams that are tailored to the needs of specific local populations.
The Strategy & Engagement Director indicated that this was an area where further work was required.
The Strategy includes priorities these were:
- PTS, and being a PTS provider of choice.
- Our Staff in the context of public health and improving the health and wellbeing of our staff.
- Neighbourhood Health and working with system partners to keep patients at home rather than convey to an Acute.
- Advanced Foundation Trust aspiration of the Board.
- WMAS and EMAS together are also currently engaged in a live discussion with the NHSE regional team on what else we could do to support non-conveyance to Emergency Departments.
The Strategy & Engagement Director asked if there was anything else that should be included.
The Chairman said this was coming together as a good document. This is the final opportunity to ensure this accurately reflects our strategy for the next 5 years.
Professor Hopkins said when looking at the vision in the document, that somewhere in between “a great place to work” and developing the organisation, should there be something around continuing development of individuals.
Professor Hopkins indicated that nothing is static, and it is recognised that this is a continually developing organisation and the document should reflect how we develop our staff to keep pace with the changing environment.
The Strategy & Engagement Director said he would develop a form of words to reflect those comments.
The Chairman referred to a linked theme to that discussion. He referred to the ever-changing workforce in terms of generational values and needs in the workplace.
He stated that there was an enormous difference between the post war “Baby Boomers” to “Generation Alpha” which includes anyone born between 2010 and 2025, making them the first cohort born entirely in the 21st century and children of “Millennials”.
They have different aspirations and values developed in a more digitally mature time in the 21st century and are described as being constantly connected through multiple digital networks, platforms, and devices and immersed in AI that “Baby Boomers” were not, due to the speed in technology developing.
The Chairman pointed out that they “Generation Alpha” are now reaching the age of 16 and in the period of this strategy will become the pool from which this Trust will recruit.
To this end the strategy should reflect the changed generational priorities and develop the Trust as an employer of choice for Millennials, and future proof recruitment opportunities that reflect the needs of the “Generation Alpha” to become their employer of choice in terms of AI and digital literacy.
The Strategy and Engagement Director indicated that this forms part of future proofing the strategy and horizon scanning in relation to emerging issues.
Any comments on the content to the Director of Strategy & Engagement in time for the strategy to be approved at the Board meeting in July 2026.
Resolved:
That the draft Five Year Strategy be received and noted.
That any comments be submitted to the Strategy & Engagement Director by the end of June.
That the Strategy be submitted to the July Board for formal approval.
05/26/08 Reports of the Director of Finance
a. Finance Update
A report of the Director of Finance was submitted.
The Director of Finance gave an update and informed the Board that the Trust reported position to the system at the end of March is a £13k surplus.
This is in line with the end-of-year forecast reported previously.
This position includes CIP which delivered £2.5m above planned levels by the end of 2025/26.
The Better Payments Practice Code results continue to be above the required 95% target overall.
Capital resource was fully utilised with a £6.1m additional delivery above the original plan.
This over delivery was approved and relates to in year PDC funding, additional CDEL received as part of the Chesire PTS contract agreement and reinvestment of asset disposals.
The Trust reported position at the end of April 2026 (month 1 is a £1m deficit from plan – this is an actual deficit of £700k compared to a planned surplus of £300k.
This relates to a reduced level of income due to the improvements to handover delays and a higher than planned spend on overtime.
Overtime restrictions are now in place with the focus being to limit spending in all areas to recover the early deficit position.
The end-of-year forecast remains as breakeven, which is the plan that the Trust has signed up to deliver.
The biggest risk of achieving that end of year position remains the level of workforce expenditure incurred to meet the resources required, alongside a reduction to income.
However, this is being closely monitored with relevant actions taken.
Another risk to the forecast is the continued rise in fuel costs, as a result of the global conflicts.
This continues to be managed with our supplier relationships and despite the market disruption and the current volatility, there have been no delivery shortages.
The reported financial position includes the CIP, which is on track for month 1 with work still ongoing to identify the gap to deliver the full year efficiency requirement.
Month 1 Better Payments Practice Code results continue to be above the required 95% target overall.
Capital resource for 2026/27 is planned with confirmation of strategic capital still in progress.
There was little spend in April with business cases progressing in the first quarter.
Run rates have been added to the report – these illustrate, at a high level, the rate of spending incurred, or income received across the year.
Comparisons to plan then illustrate the trajectory to the end of year forecast and identify where actions may be required.
Mr Nat pointed out that there had been a comprehensive and detailed discussion at the Finance & Performance (F&P) Committee.
There was included in the papers for this meeting a report on the most recent meeting of the Committee and he would in the absence of the Chair of the Committee provide an update.
He stated that although it is just month one, we need to track and stay close to handover delays and that we could have less income.
It may require trend analysis, and although it was only month one, close monitoring now may be helpful in terms of maintaining robust financial planning and remaining within the spending envelope.
The Director of Finance informed the Board that we do have scenario planning around the triangulation of workforce and handover delays going up or down and the impact on the levels of income.
The CEO confirmed that discussions have taken place at the Executive Management Board (EMB) meeting the previous day around the likely trend in lost hours over the month and the year ahead, and its impact on overtime and EMB also discussed recruitment numbers to maintain staffing levels to meet any increase in demand or to mitigate the impact of handover delays and what action the Trust would take if recruitment surpassed operational need.
He reassured the Board that he felt that EMB had gotten control of financial planning.
Mr Nat stated that he was happy that there was recognition that this is volatile situation and that close monitoring was in place.
Mrs Jasper confirmed that the meeting went through things in granular detail and possible trends.
Mrs Jasper thought that having month 1 reporting was helpful in ensuring there was robust financial planning and monitoring performance in place.
In addition, and to provide assurance to the Board Mrs Jasper the Finance & Performance Committee meets monthly so we can bring this back to the Board.
Mrs Jasper pointed out that in relation to the Better Payments Practice Code it was an area that is reviewed as part of any application for Advance Foundation Trust.
The Director of Finance said that it was an area that needed proper focus.
The Chairman asked if the audit was going to plan.
The Director of Finance confirmed she had met with External Audit last week. Nothing to raise at this point.
In terms of the process the Auditors are looking at the final elements of VFM and the opinion and then it will be the final report.
The Chairman thanked and congratulated the Director of Finance, the Finance Team and colleagues who ensued we lived within our resources and met our target.
This is a remarkable achievement given the challenges.
Resolved:
That the 2025/26 end of year results and the draft status pending audit completion be received and noted.
That the reported results for Month 1 of the 2026/27 financial year be received and noted.
That the current risks including reduced income be received and noted.
b. Security and Safety Summary 2025/26
A report of the Director of Finance was submitted.
The Director of Finance explained that the paper is for information and details the activity undertaken by the Security and Safety team which was previously reported as part of the Trust Information Pack.
The reported incidents rose by 17% from the prior financial year, with significant increases in physical and verbal assaults.
Security-related incidents such as theft and damage decreased in 2025/26 with near misses decreasing by 2%.
The Trust remains largely compliant with the NHS England Violence Prevention and Reduction Standard (VPRS), with most indicators marked compliant and improvement work ongoing in key areas such as data reporting, equality assessments, and training needs analysis.
New improved and timely reporting will be in place for 2026/27 which will be reported to Board at key points throughout the year.
Mrs Banks reported that the Quality Governance Committee of the Board receives and reviews monitoring reports in this area.
It had been raised as a concern that physical assaults have increased this year, but body worn cameras were activated on 18 occasions, which equates to 22% of reported physical assaults against our staff.
Mrs Banks asked if there is something about having conversations with staff about the increase in assaults but still low activations of body worn cameras which ultimately impacts on the success of any prosecution for assault of our staff in terms of admissible evidence to the courts.
The Director of Finance confirmed these conversations are taking place.
The Chief Operating Officer explained that assaults of staff is variable between the areas served by Hubs.
The Trust does raise the profile when cameras are activated as part of compiling evidence to enable successful prosecution.
There is also other complementary training in place such as conflict resolution training and how they manage those hostile situations with confidence.
Staff assaults have been increasing year by year and the reporting is far better now.
The Director of Finance confirmed that body worn camera usage has increased.
Mrs. Banks indicated that whilst staff who have experience may develop the skills to diffuse a situation that could become violent, graduate paramedics and more inexperienced staff may not have developed those life skills.
Mrs. Banks asked how staff received the training and development.
The Chief Operating Officer confirmed that this is discussed during the personal development conversations (PDCs) and is shown on the PDC dashboard.
The Trust felt that it was more appropriate to target individual staff needs as well rather than use a broad approach to what can be more about differing experiences.
The Director of People pointed out that figures presented looked proportionate for the number of Student’s we employ and that felt that inclusion of a comparison / proportionate total employed would help to show this and assure the Board that Student are not currently disproportionately experiencing assaults due to their lack of experience or training.
Mrs. Banks asked about training to prepare our Student Paramedics for interaction with the public as they may not have the experience and life skills. How do we prepare them and do they understand the reasons for the body worn cameras.
The Communications Director said that there was a conviction in the courts during the previous week when an employee of the Trust was assaulted by a patient and then that person urinated in the back of the Ambulance.
The body worn camera footage enabled the prosecution to secure a conviction against the individual involved.
Therefore, it was essential to reinvigorate the message in relation how important the body worn cameras are in terms of securing a conviction.
However, he pointed out that a major issue was the time it takes for the prosecution to get to courts.
He quoted an example where an incident resulted in our staff receiving a broken rib.
The incident occurred in 2024; the court case will not be heard until 2029.
The member of staff who received the injury will want to move on and this may endanger the success of the case hence better use of the onboard cameras and body worn cameras.
Staff generally have little confidence in the court process given the length of time it takes to get to court and bring closure.
Resolved:
That the report be received and noted.
That the Security and Safety reported incidents for 2025/26 and the comparisons with the prior year be received and noted.
05/26/09 Board Assurance Framework (BAF)
The Board Assurance Framework was submitted.
The Director of Nursing presented the BAF, and reported that following review by EMB, it was recommended that approval be given for Risks SR1 – Handover Delays & SR2 – Call Stacking to reduce from a risk score of 25 to a revised Risk score of 20 given data and evidence regarding reduction of delays and note that these risks are reviewed regularly to ensure scoring remains appropriate.
In addition, the Director of Nursing also proposed that at the request of the Strategy & Engagement Director that Strategic Risk 7 be removed from the BAF as the risk rating has been reduced.
It was indicated that it had initially been added to the BAF given the restructuring and clustering of the ICBs, but the risk has been reduced given the clustering has now been completed.
Mrs. Banks pointed out that the Chair of QGC Report later in the meeting highlights continued concern about the reduced staff capacity in areas such as patient engagement.
The engagement with Public, health surveys and patient forums seem less of a priority due to staffing capacity within the relevant directorate.
The Director of Nursing thanked Mrs. Banks and agreed to follow up on this in terms of the risk assessment.
The Director of Nursing indicated that following discussions at EMB and the Board regarding risks to the sustainability of PTS contracts, the Head of Risk and IG is working with the Non-Emergency Services Operations Delivery Director on the risks in relation to PTS contracts.
This will then be presented to EMB and dependent on the risk rating may be added to the BAF.
Resolved:
That the report by the Director of Nursing on the BAF be received and noted.
That for the reasons set out in the BAF approval be given to reduce SR1 – Handover Delays & SR2 – Call Stacking from a current risk score of 25 to a revised Risk score of 20 given data and evidence regarding reduction of delays and note that these risks are reviewed regularly to ensure scoring remains appropriate.
That approval be given to the request from the Strategy & Engagement Director that Engagement be removed from the BAF as a strategic risk given that the risks surrounding the review of the ICBs and move to clustering had reduced the risk rating and it will now managed within the Trust as set at the bottom of page 7 of the BAF attached.
Given discussion at EMB regarding PTS risks, The Head of Risk and IG be requested to review with the Non-Emergency Services Operations Delivery Director the risks in relation to PTS services and if appropriate recommend to the Board that this becomes the new SR 7.
05/26/10 Report of the Freedom to Speak Up (FTSU) Guardian
a. FTSU Guardian Report Q4
A report of the FTSU Guardian was submitted.
Mrs Wall gave an update and informed the Board that this Guardian report provides a summary of:
- Freedom to Speak Up activity in 20205/26 with key points identified from Quarter 4
- Summary of feedback received
- Promotional activity
- Overview of Ambassador network
- Mandatory Training for senior staff and managers
- Guardian network activity
- National Guardian’s Office update
- Amendment to the Public Interest Disclosure Act
- Outcomes from concerns
- Appendix 1 – National data comparison for the ambulance sector, comparing activity by Trust for each of the last two financial years. All Trusts other than WMAS have been anonymized.
Mrs. Wall informed the Board that whilst there had been an increase in numbers of concerns raised there was no specific trend to report in terms of the concerns raised; or out of the ordinary to bring to the attention of the Board.
There have been 42 cases reported in the fourth quarter, the joint highest reported in any quarter to date, equaling the number reported in quarter 3 this year.
Collectively, the volume of cases in the year-to-date 2025/26 is 159, representing a 21.4% rise compared to 131 in the previous year.
Regarding anonymous concerns since implementing the revised reporting form in May 2025, which gave staff the option to report anonymously or leave their contact details, 30% chose to speak up in confidence.
Work still needs to be done to promote the benefits of reporting concerns in confidence so that the matter can be fully explored by obtaining further details from them, their welfare can be checked upon, and actions / resolutions fed back.
Assurance of confidentiality and protection against detriment also needs to be enforced.
Worker Safety remains the most reported category for Quarter 4.
During 2025/26 we recruited and trained 25 additional FTSU Ambassadors.
This brings the total now to 77.
The NGO issued an update on their closure timeline and advised that the closing date has been extended and is now planned to close on 30 June 2026.
Following an engagement process, NHS England published The future of Freedom to Speak Up on 16 April 2026.
The document outlined the revised Freedom to Speak Up responsibilities, covering Guardian registry, policy and guidance, data collection, and system learning.
It also included the future of support, training, enquiries, and networks for Guardians.
A separate paper on the implications and impact of the document will be submitted to EMB, which will include information on transition arrangements and a further series of planned engagement sessions for senior healthcare leaders with FTSU responsibilities.
At the request of the Quality Governance Committee, a timeline of promotional and other work, alongside activity and ambassador inductions to provide an overview, alongside an opportunity to see correlations between promotional work and changes in volumes of concerns being raised, was made available to members of the Board if they wished to view it.
Mr Nat referred to the FTSU feedback received and welcomed the responses received.
Individuals were asked to score their satisfaction in terms of the Freedom to Speak Up Process, from 1 to 10, with 10 being extremely satisfied, and the average score for this reporting year was 9 out of 10 (8.96).
He congratulated the Guardian and her colleagues on this outcome and said it was not an insignificant outcome that should be ignored.
In doing so he referenced that individuals in the feedback were asked ‘given your experience of the FTSU Guardian, would you speak up again?’
He felt that the results were extremely positive, in that for the reporting year the feedback was:
- 21 replied YES (80.8%)
- 2 replied NO (7.7%)
- 3 replied MAYBE (11.5%)
He felt that overall, the report was very informative and transparent.
Mrs. Jasper said the invitation for the Board to meet with the FTSU Ambassadors after the last Board meeting was very helpful for the Board to hear from them.
Mrs. Jasper was very supportive of the work the organization does in relation to FTSU.
The Chairman thanked Mrs. Wall for everything the Guardians are doing.
Resolved:
That the report be received and noted.
05/26/11 Quality Reports
a. Combined Clinical Directors Quality Reports
The Combined Clinical Directors report was submitted.
The Transformation & Patient Safety Director, highlighted the following salient matters contained in the report:
- Hospital handover delays continue to impact the service delivery and contributes to delayed responses to patients in the community. The impact of hospital handover delays continues to increase the Learning from Deaths workload, which is being supported by the Trusts Learning Leads to manage the demand and this has remained as a continual action to stabilise this work.
- The Quality Governance Committee has undertaken a detailed review of Handover delays in particular the impact on patient care, causes and mitigation. The Committee has scheduled a 6-month review following original “deep dive” on Ambulance Handover delays.
- In addition, the Committee will be carrying out a detailed review of safeguarding for assurance purposes only.
- Reporting on areas of compliance continues through the Trusts Committee structure including Safeguarding, Medicines Management, Patient Safety.
- We have an MOU in place between NWAS and WMAS for Pharmacist provision as an interim measure, whilst the Trust undertakes Pharmacist recruitment. A full update on medicines management is being presented to a meeting of the Quality Governance Committee.
- We have implemented changes to JRCALC guidance (specifically in relation to Termination of Resuscitation), including All operational staff receiving 2-hour National e-learning package on JRCALC update. We are monitoring the changes but not seeing any impact.
- Updated PSIRF priorities implemented in April 2026 with alignment of Trusts clinical audit programme.
- We received a Coroners Office, Prevention of Future Deaths (PFD) in April 2026 regarding naloxone use in cardiac arrest. It was about the guidance and the feasibility of administering it in compliance with the Guidance. The Medical Director has provided a response to the Coroner referring to the JRCALC guidance. The Chairman indicated that the letter was an excellent response to the PFD.
The Medical Director pointed out having had severe hospital handover delays during the winter which had been highlighted by the Trust.
Dr Steyn stated that his concern was that given the situation was now less severe the focus on the dangers to patients may be lessened.
He believed that until the NHS target for all ambulance handovers to A&E are completed within 15 minutes with no more than 45 minutes maximum handover delay there remains significant risk to patients.
The Chairman agreed and indicated that it will remain a high-profile risk for the Trust and this Board.
Mrs Banks for purposes of assurance explained that this report had been discussed at length at the Quality Governance Committee (QGC).
Mrs Banks highlighted in particular the updated PSIRF priorities and the electronic clinical audit reporting was very positive.
The Committee had also had sight of the PFD response which the committee felt was a good response.
Resolved:
That the Combined Clinical Directors Quality Report submitted be received and noted.
That it is acknowledged that there remains the continued risks of patient harm being caused as the result of delayed responses and the stacking of calls in EOC due to continuing long handover delays, and that the Trust requires the NHS target for all ambulance handovers to A&E to be completed within 15 minutes with no more than 45 minutes maximum handover delay be implemented immediately.
b. Quality Account
A report of the Strategy & Engagement Director was submitted.
The Strategy & Engagement Director gave an update and informed the Board that the draft Quality Account is enclosed for review and approval.
Achievement of the priorities agreed for 2025/26 are reported within the document along with all other updates in respect of activities across the Trust.
The new priorities for 2026/27 are also identified.
There remains since covid, no refreshed national guidance for Quality Accounts this year, but the documents are still to be created and published by each Trust according to the normal schedule.
Whilst there is no updated guidance, it has been clearly stated that there is no requirement for external audit of the document.
At the time of writing, some statements from stakeholders are yet to be received.
All statements received prior to publishing will be incorporated into the final version.
Some final formatting will also be completed before publication; this will be done to ensure compliance with accessibility requirements.
Any further updates to data reported within this version will be incorporated and highlighted for agreement.
The document has been approved by Quality Governance Committee and Executive Management Board; it has also been received by Council of Governors and external stakeholders.
The Board of Directors was requested to approve the document, providing EMB the authority to authorise the final version on 9 June 2026 once any remaining comments have been incorporated and any final updates are made.
Any amendments or additions will be highlighted for attention and agreement.
The document will be published by the statutory deadline of 30 June 2026.
The Strategy & Engagement Director informed the Board that the Trust is starting to receive feedback from the stakeholder engagement such as the HOSCs who have received individual briefings if they asked for one, this was the case with Staffordshire and Dudley HOSCs and in large part the responses had been positive.
There were areas where the Trust is requested to reflect on areas such as the staff survey results which was highlighted by Wolverhampton Council HOSC.
The Strategy & Engagement Director indicated that the Quality Account was submitted for approval subject to the delegation to the EMB to receive any relevant responses received, and that EMB to approve publication within the timescales and then report to the July Board meeting to confirm any action taken under this delegation.
The Strategy & Engagement Director reported that when the Quality Account draft document was considered at EMB it was agreed that there was a need to read and compare the Quality Account with the Trust’s Annual Report to ensure the two documents align in terms of content.
Mrs Jasper advised the Board that the Strategy & Engagement Director and Mrs Wall are attending the next Audit Committee meeting for assurance in relation to assurance in terms of process and where it has been submitted, in addition confirmation in relation to cross referencing of both documents.
Mrs Banks as part of the governance assurance process indicated that the document was shared with the Committee in draft format and then the final draft was submitted to the last meeting of the QGC.
Mrs Banks indicated that the content of the Quality Account was comprehensive, and that it was a significant and good piece of work, and the Committee was recommending approval of its content to the Board.
Mr Nat said that the document emphasised what the Trust does for the local community as part of the system and indicated that there is a statement in the Trust’s draft strategy document, considered earlier in the meeting that set out the way the Ambulance service contributes to the community not only in terms of the staff we employ but the £400mill contribution.
The Board acknowledged the work undertaken by Mrs Wall in pulling the document together.
The Chairman asked the Strategy and Engagement to advise the Board if there are any significant comments received.
Resolved:
That the content of the Quality Account document now submitted be approved subject to the Executive Management Board, accepting any further statements from Stakeholders in relation to the Quality Account which, at the time of submission of this report to the Board, have not yet been received and authorising its publication.
That any action taken by EMB under this delegation will be reported to the next meeting of the Board of Directors.
c. Departmental Annual Reports
A report of the Strategy & Engagement Director was submitted.
Mrs Wall informed the Board that the leads of key corporate functions have produced reports to cover a summary of activities and achievements during 2025/26 and an overview of priority work areas for 2026/27.
These Annual Report underpins the Quality Account.
The following reflects the groups and committees where each report has been reviewed or is scheduled.
All reports were available on request:
- Controlled Drugs and Medicines Management (Approved by PSLG 18/05/26)
- Infection Prevention & Control (Approved by HSRE 06/05/2026)
- Patient Experience (Approved by PSLG 18/05/26)
- Safeguarding, including Prevent (Approved by PSLG 18/05/26)
- Public Health (Approved by PSLG 20/4/2026)
- Emergency Preparedness (Approved by OMT April 2026)
- Health, Safety and Risk (Approved by HSRE 06/05/2026)
- Patient Safety (Approved by PSLG 18/05/26)
- Learning from Deaths (Approved by PSLG 18/05/26)
- Freedom to Speak Up (Scheduled for EMB 26 May 2026)
- Information Governance (Approved by HSREG 06/05/26)
- Clinical Audit (Approved by PSLG 20/4/2026)
- The Data Security and Protection Toolkit Annual Report (to be completed following the DSPT national submission in June 2026)
- The Equality and Diversity Annual Report (to be published in July 2026)
Given accessibility standards on the Trust’s website the reports are in plain text.
However, it is recognised that this does not allow for more visual presentation of data and graphics.
Some departments have produced their reports in the former PowerPoint style, which will be used for their own purposes.
Where possible, these will be converted to plain text versions for subsequent publication in line with accessibility requirements.
Once approved, they will be published on the Trust’s website, supporting the Quality Account.
Resolved:
That approval be given to the annual reports submitted for publication on the Trust’s website in support of the Quality Account.
Mrs Wall left the meeting.
05/26/12 Report of the Chief Operating Officer
A report of the Chief Operating Officer was submitted highlighting various matters contained within the report.
The following was noted:
- There is increasing demand in the system this was highlighted by over 2,000 incidents, more this April than last April (2025).
- Performance remains strong having achieved 16:58 in Category 2 mean response time which is 3 minutes 52 seconds faster than the 20:50 national target, the year-to-date position nationally for the response target is 24:30 this evidences this Trust’s strong response performance.
- This has been achieved using increased overtime and reduction in the hospital handover delays by 15,000 compared with the same period in 2025.
- DCA resource hours are higher at 244,000 hours compared to 229,000 hours planned.
- Productivity has increased from 4.2 to 5 jobs on average for each shift.
- Call answering shows strong performance.
The Chairman pointed out that the last couple of days have been challenging and asked if this was due to the hot weather or Bank Holiday.
The Chief Operating Officer explained that it was a bit of both.
We also need to not become complacent in relation to hospital handover delays closely and will need to be monitored closely.
Mr Nat said that the performance was reviewed in detail at the F&P Committee and we cannot underestimate what great performance this is given the challenges faced.
The CEO said this is appreciated in April WMAS was the best performing ambulance service nationally and last was the second best for the whole of last year.
Mrs Farrington pointed out that EOC is carrying dispatch vacancies and these need to be filled in the interests of health and wellbeing of staff.
The Chief Operating Officer confirmed that the Trust was now out to advertise these vacancies.
Resolved:
That the report be received and noted.
05/26/13 Board Committee Review
A report of the Governance Director / Trust Secretary was submitted.
The Governance Director pointed out that the Health Bill has now been published, and Schedule 3 of the Health Bill sets out the revised Constitution for all Trusts which will clearly impact on the Trust’ governance structure such as rescinding the obligation to have a Membership and a Council of Governors.
This will mean that as stated in the NHS 10-year plan and alternative means of engaging with the public will be required.
The contents of the report and attachments were then presented:
- The Board of Directors Terms of Reference was submitted.
- The Trust’s Governance/Committee structure was presented.
- The Terms of Reference for each of the Board Committees and EMB was submitted following a review by the relevant Committee and EMB of its Terms of Reference.
- The Committee Membership matrix was submitted setting out membership of each Committee and also the Chairs of each Committee.
Finally, the Governance Director and Trust Secretary pointed out that since Covid Microsoft Teams software has been the default attendance means.
Following discussions with Committee Chairs it is proposed that attendance at meetings in person should be the default position with Microsoft Teams being the exception and only with the prior agreement of the Chair of each Committee.
To enable this a form of words was proposed to be incorporated into all Terms of Reference:
Meetings of the Committee/EMB will normally be held on the basis of members expected to be in attendance and participation by Microsoft Teams will be by exception only with the agreement of the Committee Chair.
| Committee Member | Audit | EMB | People | F&P | QGC | Rem & Nom | Trustee |
|---|---|---|---|---|---|---|---|
| Prof. I Cumming* | Ch | Ch | |||||
| Prof. A C Marsh* | Ch | X | X | ||||
| Ms S Banks* | X | Ch | X | X | |||
| Ms C Beechey* | X | X | X | ||||
| Mr A Brown | X | X | |||||
| Ms C Eyre* | X | X | X | ||||
| Mr M Fessal* | Ch | X | X | X | |||
| Prof. A Hopkins* | X | X | X | X | |||
| Mr N Hudson | X | X | X | ||||
| Mrs J Jasper* | Ch | X | X | X | |||
| Mr M Khan* | X | Ch | X | X | |||
| Mr V Khashu | X | ||||||
| Mr M MacGregor | X | ||||||
| Mr S Nat* | X | X | X | X | |||
| Ms K Rutter* | X | X | X | X | |||
| Dr R Steyn | X | X | X |
- That approval be given to insert the following wording into the Terms of Reference of the Board and also its Committees and EMB:
Meetings will normally be held on the basis of members expected to be in attendance, and participation by Microsoft Teams will be by exception and only with the agreement of the Committee Chair.
Resolved:
That the report be received and noted.
That the Terms of Reference of the Board of Directors be approved.
That the Committee Structure be received and noted.
That the following Terms of Reference be approved: Audit Committee
Finance & Performance Committee
Remuneration & Nominations Committee
People Committee
Quality Governance Committee
EMB
To note that each Committee has undertaken a self-assessment exercise. The outcome of the self-assessments are available upon request.
That the following committee membership matrix be approved setting out the membership and appointing the relevant Chair:
05/26/14 Board Committee Meeting Minutes & Chairs Reports
13a – Finance & Performance Committee
The Chairs Report of the Finance & Performance Committee meeting held on 19 May 2026 was submitted along with the minutes of the meeting held on 17 March 2026.
As Mushtaq Khan was not at the meeting so Mr Nat and Mrs Jasper gave an update and indicated that much of the discussion at the recent meeting of the Committee has been well aired at this meeting.
The following was noted:
- Achieved break even despite the difficult environment we find ourselves in.
- The CIP programme although fully identified for this year is not yet fully developed. It was acknowledged that this will become more difficult each year.
- Further work on the BAF including review of risk scores and consideration of emerging risks such as PTS.
- As a positive development the Board will be requested to reduce the risk rating for Strategic Risks SR1 (Hospital Handover Delays) and SR2 (Call Stacking) from 25 to 20, reflecting improvements in operational performance and system flow.
- This improvement is supported by:
- Reduced hospital handover delays and associated lost hours
- A reduction in PSIRF incidents and clinical risk, indicating improved patient safety
- Reduced operational pressure on frontline staff
- Notwithstanding this improvement, both risks remain high and subject to ongoing monitoring, with continued dependency on system-wide performance across acute hospital partners.
In relation to the BAF Mrs Jasper said the committee found it reassuring that the EMB had discussed this at length and it’s good to see the movement in the risk score.
Resolved:
That the Chairs Report of the meeting held on 19 May 2026 be received and noted.
That the minutes of the meeting held on 17 March 2026 be received and noted.
13b – People Committee
The Chairs Report of the People Committee meeting held on 13 April 2026 was submitted along with the minutes of the meeting held on 2 February 2026.
As Mohammed Fessal was not at today’s meeting Mrs Banks gave an update on the salient matters:
- Discussion took place relating to concerns around management-to-staff ratios. These remain high and were described as a potential organisational risk, reflecting growth in hub staffing without corresponding increases in substantive management capacity since 2011.
- Development of a tailored KIT Days workbook, including maternity journey support, using staff feedback and external templates to improve awareness and uptake.
- Committee self-assessment has taken place.
- Terms of reference reviewed.
- Recruitment remains on track; the Trust reported zero agency and bank use.
- Attrition reported to be in an excellent position.
- Progress on inclusion metrics; BME headcount increased and disability declarations increased.
- Staff survey Trust action plan approved at EMB.
The meeting was well attended, with evidence of effective challenge and appropriate scrutiny of the papers presented.
Mrs Banks highlighted an issue regarding access to committee papers with some documents not easily readable on iPad.
This has been escalated to IT with consideration of converting Word/Excel papers to PDF to support accessibility.
Resolved:
That the Chairs Report of the meeting held on 13 April 2026 be received and noted.
That the minutes of the meeting held on 2 February 2026 be received and noted.
13c – Quality Governance Committee (QGC)
The Chairs Report of the Quality Governance Committee meeting held on 20 May 2026 was submitted along with the minutes of the meeting held on 18 March 2026.
Suzanne Banks, Chair of the QGC, explained that a lot of the issues have already been raised in today’s meeting, but she highlighted the salient matters discussed at the meeting held on 20 May 2026:
- The meeting last week was a face-to-face meeting with 3 colleagues joining remotely.
- Risks were reviewed again and patient handover delays continue. The Acute Trust is being monitored on corridor care.
- Two recent incidents relating to significant delays in offloading a patient with a mental health crisis, and a patient who lacked capacity had a significant effect on both the patients and the staff because of delaying their care by not offloading them into ED.
- Despite being chased we are still struggling to confirm a date for the Safety Summit.
- Not all pre-alerts are being actioned in some hospitals.
- Noted the reduction of resources in Corporate Teams. Risk assessment review is due in 6 months.
Work underway is as follows:
- Review of the role and practice of Community First Responders commissioned.
- Scheduled deep dives for future meetings 2026/27 include Safeguarding and a 6-month review following original deep dive on Ambulance Handover delays.
Mrs Banks said that the meeting was quorate and there was good discussion and member engagement on all papers.
There was positive feedback from stakeholders on the Quality Account.
The proposed changes to the Claims & Coroners Report and governance reporting were agreed.
Benchmarking exercise alongside plans to recruit to the Pharmacy vacancy presented and assurance given.
Patient experience reported halting of the Patient Forum, both due to reported capacity issues within the team and the Trust needed to consider how we are going to get public and patient feedback in future.
The Governance Director and Trust Secretary pointed out that with the abolition of the Membership and Governors as proposed in the Health Bill the Trust will need to find alternative means of engaging with the public and patients.
Resolved:
That the Chairs Report of the meeting held on 20 May 2026 be received and noted.
That the minutes of the meeting held on 18 March 2026 be received and noted.
05/26/15 Board Schedule of Business
The schedule was submitted.
Resolved:
That the Board Schedule of Business be received and noted.
05/26/16 Any Other Business
There was no other business.
05/26/17 The Date of the Next Meeting
Wednesday 29 July 2026
This will include the Annual Meeting of the Membership and the Chairman pointed out that this may well be the last meeting of the Membership due to regulation changes.
The Chairman encouraged all Members of the Board to join the Council of Governors on the 27 July.
There being no other business for this meeting the Chairman brought proceedings to a close and thanked members for their attendance.