17 Oct 2024 Wilfred John Fitchett and 3 others · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Lack of legal restrictions on the licences of young and newly qualified drivers View source Lack of roadside barrier or fence preventing vehicles entering the ditch View source Vehicle licensing regime permitting young passengers to be carried by young and newly qualified drivers View source Water-filled ditch below road level beside the carriageway View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Wilfred John Fitchett and 3 others · 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
On 19 November 2023, a vehicle carrying four young men left the A4085, entered a water-filled drainage ditch and all four died from drowning; the vehicle was found on 21 November 2023. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers carrying young passengers and the risk of further deaths in similar circumstances.
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 Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Lack of legal restrictions on the licences of young and newly qualified drivers
Wider context from the report “b. Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.
c. It is noted that young drivers are exponentially more likely to be involved in a collision with each similar aged passengers in the car.
d. I am concerned that deaths will continue to occur or will occur into the future where younger persons are carried in motor vehicles being driven by newly qualified and/or young drivers.
” 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 Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Lack of roadside barrier or fence preventing vehicles entering the ditch
Wider context from the report “b. A stock fence had been erected (likely by the private landowner) concerning the lane of the road in question. It is understood that Cyngor Gwynedd had no responsibility for this given that it was on private land. The stock fence had been damaged and had not been replaced prior to the collision on 19 November 2023.
c. Whilst the evidence could not determine whether or not the fence, had it been repaired and in situ at the time of the collision, would have altered the outcome the risk to road users who leave the road accidentally is that they may land in the ditch below the road level .
d. Cyngor Gwynedd has installed a chevron board at the bend but there is no barrier or fence otherwise to prevent motor vehicles leaving the road into the ditch at this bend in the event of leaving the carriageway accidentally .
” 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 Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Vehicle licensing regime permitting young passengers to be carried by young and newly qualified drivers
Wider context from the report “b. Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these .
c. It is noted that young drivers are exponentially more likely to be involved in a collision with each similar aged passengers in the car.
d. I am concerned that deaths will continue to occur or will occur into the future where younger persons are carried in motor vehicles being driven by newly qualified and/or young drivers.
” 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 Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Water-filled ditch below road level beside the carriageway
Wider context from the report “a. The specific road area in question along the A4085 Garreg, Llanfrothen had a ditch downward from the road at the nearside of the carriageway . This fills with water during heavy periods of rainfall .
” 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 Review future options for installing a road restraint system as maintenance or wider highway improvements affect the relevant considerations.
Verbatim wording from the response “4.10 On the basis of the above, taking into account the enhancements already implemented, options in the short term to install a RRS are limited in respect of both scope and justification. However, this will be subject to review as there are other factors which may influence this. These could include future maintenance and/or wider and more significant improvements to the highway which may affect the determining considerations in relation to installing a RRS.” Source location Response from Cyngor Gwynedd Council
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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 a site-specific assessment of whether a road restraint system should be provided at the collision site.
Verbatim wording from the response “4.2 an assessment for the provision of a Road Restraint System (RRS) at the site has been undertaken.” Source location Response from Cyngor Gwynedd Council
Open published response
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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 Road restraint installation is limited by substantial funding, resource, physical, engineering, legal, environmental, land ownership and maintenance constraints.
Verbatim wording from the response “Due to lack of level verge a new restrain system cannot be easily installed without major works to create a verge which would have significant costs.” Source location Response from Cyngor Gwynedd Council
Open published response
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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 Implemented signage and passive roadside measures may be sufficient to negate the need for a road restraint system.
Verbatim wording from the response “The guidance for medium priority sites state that a road restraint system may be justified however a non-RRS approach to reducing the risk may prove sufficient to negate the need for a RRS.” Source location Response from Cyngor Gwynedd 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.
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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 Gwynedd 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 Gwynedd 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 Gwynedd 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.
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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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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 Gwynedd 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
31 Jan 2022 Eirlys Wynne Roberts · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1 Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Eirlys Wynne 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
Eirlys Wynne Roberts, aged 93, suffered a fall at a residential home, fractured her neck of femur, underwent surgery, and died a short time later. The report raised concern about the shortage and lack of timely availability of residential, EMI residential, and EMI nursing placements for elderly people whose cognitive and physical care needs change, potentially putting them 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 Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs
Wider context from the report “There was evidence heard during the Inquest that when a residential home was required given the deceased’s needs that the homes in Gwynedd were all full and that consideration would need to be given to placements outside of the area. Eventually a placement was identified. When further deterioration was noted whereby the deceased required a higher level of care by way of an EMI residential placement one was not immediately available. The deceased therefore remained at the residential home. When her needs further increased whereby an EMI nursing placement was required, again there was no availability. I am concerned by the lack of available placements for the elderly as and when their cognitive and physical needs change thereby putting them at risk. The evidence was that there is a shortage of placements and it is concerning that specific needs of the elderly cannot always be met either at all or in a timely manner.
” 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 Complete the statutory population needs assessment to inform future placement requirements.
Verbatim wording from the response “A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Work with the Health Board, social housing partners and neighbouring counties to plan, commission and develop care provision across boundaries.
Verbatim wording from the response “In the future, our hope as a local authority will be to develop a residential EMI provision at Plas Gwilym Home (as a part of Canolfan Lleu), Plas Pengwaith Home and within the development of the Penyborth site, Penrhos. We are also working in partnership with the Health Board and partners in the social housing field to develop the market further. An example of this is the plans being developed on the Penyborth site at Penrhos, Llŷn and for Canolfan Lleu, Penygroes.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Develop a new EMI unit at Hafod Mawddach Home.
Verbatim wording from the response “Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Develop an additional EMI unit at Plas Hedd Home.
Verbatim wording from the response “Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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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 Extend EMI provision within Council homes.
Verbatim wording from the response “Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Present the North Wales care market stability report to the Government during summer 2022.
Verbatim wording from the response “We are also considering the care market and its ability to respond to the demand for care services today and in the future, and we intend to present the report on the 'Stability of the Care Market in North Wales' to the Government during the summer 2022. The conclusions within this report will show the steps that need to be addressed in order to ensure a suitable provision to meet the demand.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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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 Consider providing nursing care internally at a Gwynedd site to increase nursing provision and stabilise the care market.
Verbatim wording from the response “As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Undertake more localised detailed work to assess whether future placement numbers are sufficient.
Verbatim wording from the response “A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high” Source location 2022-0034-Response-from-Gwynedd-Council_Published
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 Convert general residential beds into residential EMI beds in Council homes, supported by building investment and additional staffing.
Verbatim wording from the response “In addition, we are facing a challenge with the availability of residential EMI placements. In terms of general residential placements, the availability of placements against the demand is much better. In order to respond to the lack of residential EMI placements, the Council, for a number of years, has converted general residential beds into residential EMI beds within the internal homes. This work has involved a substantial investment in the buildings and in additional staff. Over the past 5 years, Gwynedd Council has almost doubled the number of Residential EMI beds in our homes.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
Open published response
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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 Legislative restrictions prevent the Council from providing nursing care directly, making response to a nursing-home closure challenging.
Verbatim wording from the response “As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
Open published response
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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 link between the incident and availability of an EMI placement is not entirely clear.
Verbatim wording from the response “The situation of waiting for a bed in an alternative placement is quite common for a number of individuals across the country. Of course, we have given careful consideration to the notice, however as I have previously noted, the link between the circumstances of the incident and the availability of an EMI placement is not entirely clear. However, wherever a higher level of care is needed when attempting to find or secure an appropriate placement, more advanced care arrangements are put in place in order to safeguard the individual until a solution is reached. This is based on appropriate risk assessments and care plans.” Source location 2022-0034-Response-from-Gwynedd-Council_Published
Open published response
11 Nov 2015 Alexander Stuart Hadley and Steffan Robert Vernon · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1 Lack of warnings about dangerous currents in the waterfall pool View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Stuart Hadley and Steffan Robert Vernon · 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
On 5 June 2015, Alexander Stuart Hadley and Steffan Robert Vernon drowned while swimming in a pool below a waterfall at Llanberis. The concern was that people were unaware of the dangerous currents and other hazards, creating a risk of further deaths, and that warning signage was needed.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gwynedd Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about dangerous currents in the waterfall pool
Wider context from the report “(1) The two deceased men were unaware of the dangerous currents in the pool directly below the waterfall and the evidence indicated that other people were also unaware of the dangers . As the waterfall is in close proximity to the village of Llanberis and is easily accessible other people could die in identical circumstances and I am therefore of the opinion that a sign should be erected to warn people of the dangerous characteristics of the waterfall pool.
” 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 Install safety warning signs near the waterfall pool warning visitors not to swim and highlighting the risk from underwater currents.
Verbatim wording from the response “Mae Cyngor Gwynedd yn dal rhyddfraint safle’r pwll lle digwyddodd y ddamwain, ond mae’r safle wedi ei brydlesu. Er hynny, mae’r Cyngor wedi gwneud trefniadau yn unol â’r gorchymyn yn dilyn y cwest, i osod rhybuddion diogelwch na ddylid ymdrochi yn y pwll ger Rhaeadr Afon Arddu, Llanberis.” Source location 2015-0433-Response
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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 Severe weather temporarily prevents safely accessing the site to install safety warning signs.
Verbatim wording from the response “Mae arwyddion wedi eu harchebu a’u derbyn a bwriedir eu gosod ar greigiau gerllaw pwll y rhaeadr er mwyn blaen-rhybuddio ymwelwyr i’r safle o’r perygl o farwolaeth sy’n bodoli oherwydd ceryntau tanddwr. Bydd yr arwyddion yn cael eu gosod cyn gynted â phosibl. Mae’r tywydd gwyllt diweddar wedi oedi’r gwaith gan fod angen sicrhau llwybr diogel i weithwyr gyrraedd y safle. Byddant yn cael eu gosod unwaith bydd tywydd yn caniatáu’r gwaith gael ei gynnal yn ddiogel a gobeithir y bydd wedi ei gwblhau erbyn diwedd mis Ionawr 2016.” Source location 2015-0433-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations