1 Mar 2017 Ceriann Richards · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Delays in ambulance-to-hospital handover View source
Linked responses
Aneurin Bevan University LHB the Minister for Social Services and Public Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Aneurin Bevan University LHB
Implement a standard operating procedure enabling bed and site management teams to use available capacity across both hospitals during ambulance handover pressure.
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Aneurin Bevan University LHB
Implement escalation protocols directing emergency department staff and bed management teams to receive and off-load ambulances when capacity is constrained.
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Aneurin Bevan University LHB
Implement and continually review a Winter Resilience Plan to manage winter demand and capacity pressures and strengthen the response to ambulance handover delays.
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Aneurin Bevan University LHB
Implement two transfer teams to move patients from wards and emergency departments.
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Aneurin Bevan University LHB
Introduce discharge facilitators on each ward at Royal Gwent Hospital.
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Aneurin Bevan University LHB
Implement the transfer-team and discharge-facilitator model at Nevill Hall Hospital.
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Aneurin Bevan University LHB
Monitor the implemented actions and their impact on ambulance handover performance.
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the Minister for Social Services and Public Health
Undertake national and local work to reduce inappropriate admissions, improve hospital patient flow, and expand community capacity for timely discharge.
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AI-generated summary
Ceriann Richards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ceriann Richards was found acutely unwell and suffering seizures at home on 14 August 2016. An ambulance took approximately three hours to convey her to hospital, where she died later that morning. A post-mortem found very high, toxic levels of Venlafaxine, while the principal concern was delay in ambulance despatch linked to hospital handover delays.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance-to-hospital handover
Wider context from the report “(1) The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals within the Aneurin Bevan University Health Board Areas which on that day for the Royal Gwent Hospital were of an average of 107 minutes up to a maximum of 279 minutes and for the Neville Hall Hospital with an average delay of 43 minutes and the longest delay of 93 minutes. The evidence revealed that the agreed “handover time” is 15 minutes. The evidence further revealed that since guidance was issued in the spring of 2016 in relation to the handover from ambulance crews to hospital staff the position has worsened and in the order of 140 to 200 hours are lost each day equating to 10 to 20 vehicles being off road for the whole day across the Welsh Ambulance Trusts Area .
” Source location Ceriann Richards · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standard operating procedure enabling bed and site management teams to use available capacity across both hospitals during ambulance handover pressure.
Verbatim wording from the response “• A Standard Operating Procedure has been implemented which supports bed management and site management teams in utilising all bed capacity across both Nevill Hall Hospital (NHH) and Royal Gwent Hospital (RGH) when ambulances are in danger of being held outside of our Emergency Departments (ED). This protocol was adopted by the Health Board’s Urgent Care Board and is part of the Health Board Escalation Process, which was reviewed and re written in preparation for winter 2016/2017.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement escalation protocols directing emergency department staff and bed management teams to receive and off-load ambulances when capacity is constrained.
Verbatim wording from the response “• The Health Board has identified escalation protocols which are used to guide ED staff in the operational procedures for receiving and off-loading ambulances. These include a preparatory escalation when more than three crews are on site and limited capacity exists to off load further ambulances, are expected to arrive. This escalation is to the bed management teams who are required to move patients from ED to the available bed capacity with immediate effect.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and continually review a Winter Resilience Plan to manage winter demand and capacity pressures and strengthen the response to ambulance handover delays.
Verbatim wording from the response “• The Health Board has a Winter Resilience Plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. This plan is shared with all local stakeholders and partners to ensure the actions and initiatives described within the plan are shared and agreed prior to implementation. The Health Board has continually reviewed the plan on a month by month basis at its Urgent Care Board. This has led to a number of actions being reinforced since the implementation of the plan to ensure a more robust response to ambulance handover pressures.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement two transfer teams to move patients from wards and emergency departments.
Verbatim wording from the response “This has seen the implementation of two transfer teams, one transferring out of the wards and one transferring out of ED. Discharge facilitators have also been introduced on each of the wards at RGH. There is work commencing to implement this model in NHH. Breaking the Cycle has led to improved patient flow within the hospital, reduced congestion in our EDs and has led to a consistent approach over seven days a week.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce discharge facilitators on each ward at Royal Gwent Hospital.
Verbatim wording from the response “This has seen the implementation of two transfer teams, one transferring out of the wards and one transferring out of ED. Discharge facilitators have also been introduced on each of the wards at RGH. There is work commencing to implement this model in NHH. Breaking the Cycle has led to improved patient flow within the hospital, reduced congestion in our EDs and has led to a consistent approach over seven days a week.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the transfer-team and discharge-facilitator model at Nevill Hall Hospital.
Verbatim wording from the response “This has seen the implementation of two transfer teams, one transferring out of the wards and one transferring out of ED. Discharge facilitators have also been introduced on each of the wards at RGH. There is work commencing to implement this model in NHH. Breaking the Cycle has led to improved patient flow within the hospital, reduced congestion in our EDs and has led to a consistent approach over seven days a week.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the implemented actions and their impact on ambulance handover performance.
Verbatim wording from the response “The actions implemented by the Health Board have been captured in the attached action plan. Please be assured that these actions and their impact on ambulance handover performance are monitored by the Health Board.” Source location 2017-0041-Response-by-University-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake national and local work to reduce inappropriate admissions, improve hospital patient flow, and expand community capacity for timely discharge.
Verbatim wording from the response “You raised concerns regarding significant hand over delays within two district hospitals in the Aneurin Bevan University Health Board areas, resulting in the delay of an ambulance being dispatched. We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service’s ability to respond to subsequent calls in the community, but also on patient’s experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital, improving patient flow through the hospital system and enabling greater capacity in the community to support timely discharge.” Source location 2017-0041-Response-by-Welsh-Government
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation WAST and local health boards share responsibility for ensuring safe and timely patient handover from ambulance crews to hospitals.
Verbatim wording from the response “The Welsh Ambulance Services NHS Trust (WAST) and local health boards have shared responsibility for ensuring the safe and timely handover of patients from ambulance crews to hospital teams and I expect health boards and WAST to continue to work together to reduce handover delays and to divert demand around the system during busy periods as well as improving patient flow through hospitals” Source location 2017-0041-Response-by-Welsh-Government
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Concerns raised 1
Delays in transferring patients from ambulances and releasing ambulance resources for other calls View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Pamela June Conway · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in transferring patients from ambulances and releasing ambulance resources for other calls
Wider context from the report “1. That notwithstanding changes which have been made by both BCUHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.
” Source location Pamela June Conway · Prevention of Future Deaths report
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26 May 2016 Peter Scott · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Delays in hospital handover of ambulance patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Midlands Ambulance Service NHS Trust the 22 CCGs across the East Midlands region
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
the 22 CCGs across the East Midlands region
Work with EMAS and acute providers to reduce pre-clinical handover delays and release crews for other emergencies.
View source
East Midlands Ambulance Service NHS Trust
Continue escalating hospital handover delays and working with regulators, commissioners, hospitals and the wider health and social care system to improve them.
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East Midlands Ambulance Service NHS Trust
Maintain daily contact and joint working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays.
View source
East Midlands Ambulance Service NHS Trust
Increase the number of paramedics based at hospitals to support patient triage and departmental flow.
View source
East Midlands Ambulance Service NHS Trust
Introduce a booking system with priority patient assessment during hospital delays.
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East Midlands Ambulance Service NHS Trust
Install ambulance arrival screens at QMC to provide real-time handover data and identify delays.
View source
East Midlands Ambulance Service NHS Trust
Reintroduce monthly meetings with QMC and commissioners to identify improvements to ambulance turnaround times.
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Peter Scott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals . I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” Source location Peter Scott · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with EMAS and acute providers to reduce pre-clinical handover delays and release crews for other emergencies.
Verbatim wording from the response “Commissioners are actively working with EMAS and acute providers to reduce the number of patients who are waiting to have pre-clinical handover, thus releasing crews to be available to respond to other emergencies who require an ambulance response.” Source location 2016-0199-Response-by-Hardwick-CCG
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue escalating hospital handover delays and working with regulators, commissioners, hospitals and the wider health and social care system to improve them.
Verbatim wording from the response “That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain daily contact and joint working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays.
Verbatim wording from the response “• Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce delays” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of paramedics based at hospitals to support patient triage and departmental flow.
Verbatim wording from the response “• Increased number of paramedics based at hospitals to support their teams with the triage of patients and flow through the department” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a booking system with priority patient assessment during hospital delays.
Verbatim wording from the response “• A new booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when delays are being experienced” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install ambulance arrival screens at QMC to provide real-time handover data and identify delays.
Verbatim wording from the response “Since March 2016 the QMC has engaged with EMAS to install Ambulance arrival screens. Unlike RFID which used electronic tags the ambulance arrivals screen uses a simple touchscreen interface based on a webpage. This new process provides real time data to both QMC and EMAS which allows both to see delays as they happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete. The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reintroduce monthly meetings with QMC and commissioners to identify improvements to ambulance turnaround times.
Verbatim wording from the response “The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time.” Source location 2016-0199-Response-by-East-Midlands-Ambulance-Service
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12 Oct 2015 Mrs Withers · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Delays in ambulance staff handover to hospital View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mrs Withers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance staff handover to hospital
Wider context from the report “5) The policy and protocol in relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover of patient to hospital .)
” Source location Mrs Withers · Prevention of Future Deaths report
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21 May 2015 Barbara Patterson · Prevention of Future Deaths report Northumberland (North)
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Concerns raised 1
Delays in ambulance crew handover at hospitals reducing ambulance availability View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Care Quality Commission
Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
View source
Care Quality Commission
Meet with NEAS in September 2015 to discuss patient handover management and collaboration with providers and stakeholders.
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Barbara Patterson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance crew handover at hospitals reducing ambulance availability
Wider context from the report “6. During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff .
” Source location Barbara Patterson · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
Verbatim wording from the response “The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence to demonstrate that they understand their role and responsibilities in relation to call handlers and that they provide regular monitoring to ensure that the system is functioning at an appropriate level.” Source location 2015-0198-Response-by-Care-Quality-Commission
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with NEAS in September 2015 to discuss patient handover management and collaboration with providers and stakeholders.
Verbatim wording from the response “We will be meeting with NEAS in September 2015 to discuss how they are managing the handover process to A & E services and how they are working collaboratively with all providers and stakeholders to ensure a smooth and timely handover process. In addition, this issue will be reviewed as part of our planned full comprehensive inspection of North East Ambulance Service (NEAS).” Source location 2015-0198-Response-by-Care-Quality-Commission
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Concerns raised 1
Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB Welsh Ambulance Services NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
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Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
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Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Investigate serious incidents involving both organisations jointly and share the resulting learning.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Consult on and ratify a North Wales escalation protocol before implementing it across the area.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
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Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
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Clive Harold Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
Wider context from the report “2. That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls . Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” Source location Clive Harold Turner · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
Verbatim wording from the response “BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
Verbatim wording from the response “BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.
Verbatim wording from the response “The audit of ambulance handover to provide assurance in relation to patient safety during this period of care has been revised by the BCUHB Associate Medical Director for Unscheduled Care. The new process has been piloted at one of the Emergency Departments in North Wales and following some amendment will be implemented across BCUHB and reported monthly. This has already commenced in Ysbyty Glan Clwyd.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate serious incidents involving both organisations jointly and share the resulting learning.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on and ratify a North Wales escalation protocol before implementing it across the area.
Verbatim wording from the response “BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
Verbatim wording from the response “BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
Verbatim wording from the response “There is engagement at all levels between the Trust and BCUHB, with conference calls arranged to agree joint action plans to address ongoing delays. Duty Control Managers from the Trust will initially contact the Hospital Clinical Site Managers if ambulances are delayed. The escalation process will continue with the Trusts Locality Managers contacting the Senior Site Operational Managers in BCUHB and then the Trusts Head of Service engaging with the Chief Operating Officer within BCUHB out of hours as there is an ‘On Call’ system Bronze to Bronze, Silver to Silver and Gold to Gold engagement between both organisations to ensure that a seamless escalation process exists.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
Concerns raised 1
Failure of Emergency Department patient handover practices to prevent unacceptable delays View source
Linked responses
Betsi Cadwaladr University LHB Welsh Ambulance Services NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Communicate handover-delay risks and patient-flow responsibilities to clinical, operational and senior medical staff.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Commission joint senior-manager workstreams to improve unscheduled-care flow and signpost patients to alternative care pathways.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Amend Llandudno Minor Injuries Unit access criteria to treat more patients locally.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Perform monthly clinical audits of patients delayed in ambulances outside Emergency Departments and use findings to improve patient flow.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Agree and implement a joint flow chart addressing clinical risks for patients waiting in ambulances.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Implement the Frailty Programme to support early discharge across the Health Board.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Complete and agree an All-Wales Handover Policy for evidence-based patient handover between clinical teams.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Continue participating in the National Patient Flow Collaborative to improve unscheduled-care consistency and sustainability.
View source See 5 more actions
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AI-generated summary
Frederick Douglas Pring · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Frederick Douglas Pring experienced chest pains, but no ambulance was available after his first emergency call because of delays handing over patients at hospitals and ambulance crews being on rest breaks. He died at home on 21 March 2013 before an ambulance arrived; a post-mortem identified ischaemic heart disease and severe chronic obstructive pulmonary disease. The principal concern was that delays in patient handovers at Emergency Departments left patients waiting in ambulances and made ambulance resources unavailable for other calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of Emergency Department patient handover practices to prevent unacceptable delays
Wider context from the report “That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls . Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” Source location Frederick Douglas Pring · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate handover-delay risks and patient-flow responsibilities to clinical, operational and senior medical staff.
Verbatim wording from the response “The issues which you have raised are vitally important and the Health Board is committed to working with the Ambulance Trust and other partners to improve the current situation as a matter of urgency. The BCUHB Medical Director has communicated these issues to all Clinical Leaders, Consultant Medical Staff and NHS Professional Managers across the Health Board. (Please see Appendices 2 & 3)” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission joint senior-manager workstreams to improve unscheduled-care flow and signpost patients to alternative care pathways.
Verbatim wording from the response “A ‘Delivery Group’ has been commissioned by the Local Health Board comprising of Senior Managers from the two organisations to oversee developments within Unscheduled Care in North Wales. The Group has various work streams to implement approaches which will improve flow and signpost patients to alternative pathways of care, as opposed to conveying to Emergency Departments by default. In line with the practice in the other Clinical Contact Centres, Advanced Paramedic Practitioners (APPs) are now working within the Clinical Contact Centres in order to enhance patient safety and to provide clinical advice to the Clinical Contact operational WAST outcalls, and also to patients and relatives who require our services.” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend Llandudno Minor Injuries Unit access criteria to treat more patients locally.
Verbatim wording from the response “• Redefining ‘border’ areas to equate the volume of WAST attendances at the three DGHs;” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Perform monthly clinical audits of patients delayed in ambulances outside Emergency Departments and use findings to improve patient flow.
Verbatim wording from the response “(1) There will be monthly clinical audits performed to provide assurance regarding the safe management of patients who are delayed in Ambulances outside Emergency Departments prior to admission. The audits will facilitate the implementation of practice changes which improve patient flow. The results of the audit will be presented to the Medical Director, Director of Nursing, Interim Chief Operating Officer, local Hospital Management Teams, local Patient Safety Groups to ensure Health Board assurance. The audit tool is attached (Please see Appendix 4).” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree and implement a joint flow chart addressing clinical risks for patients waiting in ambulances.
Verbatim wording from the response “(2) WAST and the Health Board have accelerated the discussion which was taking place relating to agreement and implementation of a ‘flow chart’ (Please see Appendix 5 (in draft)) to address the clinical risks relating to patients waiting in Ambulances. This is being further discussed at a meeting on Thursday 27 March 2014.” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Frailty Programme to support early discharge across the Health Board.
Verbatim wording from the response “There will be a focus on implementing the “Frailty Programme” to provide early supportive discharge across the Health Board. The Health Board has two teams taking part in the National Patient Flow Collaborative which has clear aims to make consistent and sustainable improvements to Unscheduled Care.” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and agree an All-Wales Handover Policy for evidence-based patient handover between clinical teams.
Verbatim wording from the response “(3) WAST and the Health Board are working together with colleagues across Wales regarding completion of an All Wales Handover Policy which describes evidence based processes for patient handover between clinical teams. We will forward this to you as soon as it is completed and agreed.” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue participating in the National Patient Flow Collaborative to improve unscheduled-care consistency and sustainability.
Verbatim wording from the response “There will be a focus on implementing the “Frailty Programme” to provide early supportive discharge across the Health Board. The Health Board has two teams taking part in the National Patient Flow Collaborative which has clear aims to make consistent and sustainable improvements to Unscheduled Care.” Source location 2014-0024-Response-by-Welsh-Ambulance-Service
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.