Concerns raised 3 Failure to maintain the general condition of the highway near the Sun Trevor Public House View source Failure to control surface water and flooding on the A539 near the Wenfrwd Pocket Park entrance View source Failure to control flooding on the highway near the Sun Trevor Public House View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Michael Thomas · 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
John Michael Thomas died on 2 December 2023 after losing control of the motorcycle he was riding and colliding with an oncoming vehicle, sustaining fatal injuries. Witness evidence indicated that the motorcycle may have slipped on the road, and concerns were raised about flooding and the general condition of parts of the A539, including issues previously brought to the Local Authority’s attention.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the general condition of the highway near the Sun Trevor Public House
Wider context from the report “Initial indications by way of witness evidence suggest that the loss of control occurred as a result of Mr Thomas’ motorcycle “slipping on the road”.
My understanding is that this has occurred near to the Sun Trevor Public House , and I have been made aware that some issues regarding flooding and the general condition of this part of the highway had been made known to the Local Authority prior to the accident.
Furthermore my understanding is that concerns have also been raised with the Local Authority in relation to surface water/flooding on another part of the A539 near to Llangollen, namely near to the Wenfrwd Pocket Park entrance.
I am therefore concerned that if action is not taken to remedy these issues, there is a risk that future deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control surface water and flooding on the A539 near the Wenfrwd Pocket Park entrance
Wider context from the report “Initial indications by way of witness evidence suggest that the loss of control occurred as a result of Mr Thomas’ motorcycle “slipping on the road”.
My understanding is that this has occurred near to the Sun Trevor Public House, and I have been made aware that some issues regarding flooding and the general condition of this part of the highway had been made known to the Local Authority prior to the accident.
Furthermore my understanding is that concerns have also been raised with the Local Authority in relation to surface water/flooding on another part of the A539 near to Llangollen, namely near to the Wenfrwd Pocket Park entrance .
I am therefore concerned that if action is not taken to remedy these issues, there is a risk that future deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control flooding on the highway near the Sun Trevor Public House
Wider context from the report “Initial indications by way of witness evidence suggest that the loss of control occurred as a result of Mr Thomas’ motorcycle “slipping on the road”.
My understanding is that this has occurred near to the Sun Trevor Public House , and I have been made aware that some issues regarding flooding and the general condition of this part of the highway had been made known to the Local Authority prior to the accident.
Furthermore my understanding is that concerns have also been raised with the Local Authority in relation to surface water/flooding on another part of the A539 near to Llangollen, namely near to the Wenfrwd Pocket Park entrance.
I am therefore concerned that if action is not taken to remedy these issues, there is a risk that future deaths may occur.
” Open source report
×
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 Rectify private-land drainage flows and clear debris from the historical stone drainage feature.
Verbatim wording from the response “5.1 On the north side of the road there is a stone feature which collects run – off from the land behind it and feeds it into a culvert which again runs under the carriageway to outfall into the canal. This is shown as Location C on the plan at Appendix 2.” Source location Response from Denbigshire County Council
Open published response
×
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 Add the drainage feature to the critical-culvert list and monitor it more closely.
Verbatim wording from the response “5.3 The council has a list of critical culverts which are known to require higher maintenance standards and this feature will now be added to a monitored more closely.” Source location Response from Denbigshire County Council
Open published response
×
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 Erect warning signs at the Wenffrwd Junction and Sun Inn locations alerting motorists to possible water or ice.
Verbatim wording from the response “6.5 As an additional safety measure, the Council has also erected warning signs on the A539 at both the Wenffrwd Junction location and the Sun Inn location. These warning signs alert motorists to the possibility of the presence of water or ice.” Source location Response from Denbigshire County Council
Open published response
×
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 investigating drainage improvements at the Sun Inn location.
Verbatim wording from the response “4.2 At this location a drainage system from an adjacent road flows into a manhole which is partially blocked. As a result, there is an overflow which runs on the highway to flow into a gully approximately 70 metres away, before draining under the road and into the canal.” Source location Response from Denbigshire County Council
Open published response
×
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 Clear storm-affected drainage gullies and channels on the A539.
Verbatim wording from the response “6.4 Following the extensive rainfall and disruption caused by Storm Babet on 20th October 2023, the Council implemented a specific response action of addressing the impact of the storm on drainage gullies and channels on the A539. This work has been completed with all gullies and channels being cleared.” Source location Response from Denbigshire County Council
Open published response
×
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 Contact the adjacent field owner about possible land alterations to help retain excess water.
Verbatim wording from the response “3.4 As a matter of completeness, the Council will contact the owner of the field adjacent to the highway to see if any alterations could be made to this private land that may assist in retaining the water on the land on the occasions when it becomes saturated.” Source location Response from Denbigshire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Wenffrwd surface-water issue is not considered to require remedial action because it occurs only during heavy or extended rainfall.
Verbatim wording from the response “3.3 Prior to the Report from HM Coroner, the Council was aware of the aforementioned issue at this location. It was not (and is not) considered to present a specific safety concern or an issue that requires remedial action. As above, such issues are common across the highway network, particularly in rural locations and it is not caused by an issue related to the highway infrastructure. The issue only presents at times of heavy or extensive rainfall. It does not result in an amount of water that makes the highway in any way unpassable for traffic and the location is the subject of winter maintenance and gritting in accordance with the Council’s winter maintenance policy.” Source location Response from Denbigshire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Wenffrwd runoff is not a specific safety concern, does not make the highway impassable, and is unrelated to highway infrastructure.
Verbatim wording from the response “3.3 Prior to the Report from HM Coroner, the Council was aware of the aforementioned issue at this location. It was not (and is not) considered to present a specific safety concern or an issue that requires remedial action. As above, such issues are common across the highway network, particularly in rural locations and it is not caused by an issue related to the highway infrastructure. The issue only presents at times of heavy or extensive rainfall. It does not result in an amount of water that makes the highway in any way unpassable for traffic and the location is the subject of winter maintenance and gritting in accordance with the Council’s winter maintenance policy.” Source location Response from Denbigshire County Council
Open published response
10 Jul 2023 Mary Elizabeth Jones · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 3 Delays in ambulance response and arrival View source Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies View source Inability to offload patients from ambulances into Emergency Departments in a timely manner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mary Elizabeth Jones · 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
Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response and arrival
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inability to offload patients from ambulances into Emergency Departments in a timely manner
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales .
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” Open source report
Concerns raised 3 Delays in ambulance attendance View source Inadequate cohesive forward planning for short-term pressures and longer-term solutions View source Lack of adequate social care placements or community care for patients medically fit for hospital discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emlyn Victor Roberts · 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
Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable .
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times , was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better .
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate cohesive forward planning for short-term pressures and longer-term solutions
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community ).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” Open source report
Concerns raised 4 Delays in ambulance handover at hospitals View source Failure to maintain timely ambulance availability and arrival for patients View source Insufficient social care capacity causing hospital patient-flow and ambulance offload delays View source Lack of meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Frickel · 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
Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals ).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely ambulance availability and arrival for patients
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available .
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report
Concerns raised 3 Delays in ambulances arriving to patients View source Delays in ambulance handover at hospitals View source Inadequate social care placements or community care for patients medically fit for discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leonard Charles Harmsworth · 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
Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulances arriving to patients
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals .
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate social care placements or community care for patients medically fit for discharge
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community ).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report
Concerns raised 4 Delays in emergency department patient handover View source Failure to maintain adequate emergency department staffing View source Insufficient hospital bed capacity for admissions View source Failure of hospital patient flow and delayed transfer of care processes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lilly Baxandall · 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
Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency department patient handover
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls" .
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays /bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate emergency department staffing
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients" .
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital bed capacity for admissions
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions ”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care .
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment ”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report
Concerns raised 4 Delays in scheduling appropriate professional meetings View source Insufficient DSS input into discharge safety plans View source Failure to conduct further assessments when action is required View source Failure to obtain independent senior review of case closure decisions View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Laura Beth Newlands · 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
Laura Beth Newlands was known to Denbighshire Social Services because of concerns about self-harm related to difficult home circumstances. After her case was closed, a delay in arranging a professionals’ meeting meant that further support was not provided before she took her own life by overdose four days before the scheduled meeting. The report identified concerns about incomplete safety-plan input, delays in responding to risk, and the decision to close and not reopen the case.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in scheduling appropriate professional meetings
Wider context from the report “2. A delay in scheduling an appropriate meeting of Professionals resulted in a missed opportunity to provide support and protection of a young person at risk and there was not therefore a prompt response to a crisis
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient DSS input into discharge safety plans
Wider context from the report “1. Although a “safety plan” is prepared by CAMHS at the time of discharge from hospital, there does not appear to be sufficient input to this document by DSS with the result that those caring for a young person at risk may have incomplete written information available to them to properly ensure the safety of the young person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct further assessments when action is required
Wider context from the report “3. The decision to close the case (and then not to reopen the same) by DSS resulted in there being no further assessments conducted at a time when action should have been taken and could have resulted in additional support for the deceased and her family. Such a decision may not have been made if the case had been reviewed by a senior staff member who was not directly involved in the investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain independent senior review of case closure decisions
Wider context from the report “3. The decision to close the case (and then not to reopen the same) by DSS resulted in there being no further assessments conducted at a time when action should have been taken and could have resulted in additional support for the deceased and her family. Such a decision may not have been made if the case had been reviewed by a senior staff member who was not directly involved in the investigation .
” Open source report
Concerns raised 1 Tripping hazard in the location View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Garry Arthur Colin Daltry · 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
Garry Arthur Colin Daltry left a New Year's Eve party, tripped over a low wall on the promenade, and fell onto a beach access ramp. He sustained blunt force injuries to his head and neck and died at the scene; the report identified the tripping hazard as a concern because others could fall and suffer fatal injuries.
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. The report was sent to Denbighshire County Council; that does not assign responsibility.
PFD Monitor interpretation Tripping hazard in the location
Wider context from the report “That unless steps are taken to mitigate the tripping hazard in this location , then other people may fall sustaining injuries which could lead to future deaths.
” Open source report
×
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 Carry out a joint boundary-to-boundary inspection of the coastal areas with responsible engineers and Corporate Health and Safety.
Verbatim wording from the response “Because the overall risk is considered to fall within the broadly acceptable region DCC feels that any measures it puts in place to further reduce the risk must be carefully considered i.e. installing railings in selected areas may cause visitors to believe that where railings are absent no risk exists. We therefore feel that the installation of additional railings has to be assessed during the boundary to boundary inspection identified as one of our proposed actions.” Source location 2014-0295-Response-by-Denbigshire-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lighting the exposed vicinity is not reasonably practicable because installation and maintenance costs would outweigh long-term public benefit.
Verbatim wording from the response “In section 5 of the regulation 28 report it is identified that the area was not lit. The County Council does not have a duty to light highways and footpaths but has the discretion to do so. Fitting luminaires in this exposed vicinity is not considered to be reasonably practicable as the installation and maintenance costs would far outweigh any long term benefit to the public.” Source location 2014-0295-Response-by-Denbigshire-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remedial works identified through risk assessment will be undertaken only as funding permits because none of the issues presents imminent danger.
Verbatim wording from the response “• Engineers to review the prioritised actions identified in the risk assessment and carry out remedial actions as funding permits. Open timescale as none of the issues identified are considered to pose imminent danger” Source location 2014-0295-Response-by-Denbigshire-County-Council
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations