Recipient

Isle of Anglesey County Council

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First report 30 Jan 2015•Latest report 10 Jul 2023

Recipient record

Reports, concerns and published responses

Local government · Welsh county council. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
5

Naming this recipient

Published responses
20%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
3

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

20%published responses found
3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Isle of Anglesey County Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North West Wales

    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 Isle of Anglesey 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 Isle of Anglesey 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 Isle of Anglesey 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

  2. North Wales (East and Central)

    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 Isle of Anglesey 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 Isle of Anglesey 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 Isle of Anglesey 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

  3. North Wales (East and Central)

    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 Isle of Anglesey 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 Isle of Anglesey 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 Isle of Anglesey 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 Isle of Anglesey 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

  4. North Wales (East and Central)

    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 Isle of Anglesey 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 Isle of Anglesey 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 Isle of Anglesey 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

  5. North West Wales

    AI-generated summary

    ISAAC NASH · 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 29 August 2014, 12-year-old Isaac Nash was swept out to sea by strong tidal currents while playing in shallow water at Aberffraw Bay, and his body was never found. The report raised concern that the estuary area had strong currents that were not identifiable to beach users without local knowledge and was not signposted.

    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 Isle of Anglesey County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of warnings about strong tidal currents in the river estuary part of Aberffraw Bay

    Wider context from the report

    “(1) Whereas it is acknowledged that there is no such thing as a safe beach Aberffraw Bay is generally considered to be a beach that is safe for children. Unfortunately, the area where the river estuary is located is, at times, subject to very strong currents and there is no way by which a person using the beach can be aware of this other than by having local knowledge. In this case, the adults accompanying the deceased were extremely sensible and safety conscious but could not have been aware of the strong tidal conditions prevailing when the children were playing on the beach. If they had been aware of the strong tide at that time they may either have not gone onto the beach or would have chosen a location in the bay where the tidal stream is not great and would have ensured that the children would not stray into the strong tidal area. I would suggest that you consider erecting signs to warn the public of the potential danger in the river estuary part of Aberffraw Bay. ”
    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

    Erect a warning sign in the car park highlighting the potential dangers at Trwyn Du before the Easter Bank Holiday.

    Verbatim wording from the response

    “3. Following the action in 1 and 2 above, a new warning sign is to be placed in the car park. This sign draws particular attention to the potential dangers at Trwyn Du. In dialogue with the Aberffraw Community Council and the Bodorgan Estate, the landowner, we have attempted to strike the right balance between the safety issues and the local tourist industry in the village of Aberffraw.”

    Source location

    2015-0028-Response-Isle-of-Anglesey-County-Council
    Page 1 · response
    Published 30 January 2015

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

20%
20%All other recipients 58%
0%100%

How actions were described at the time

This respondent
67%33%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026