Concerns raised 5 Lack of an effective rota system for consistent Community First Responder cover View source Failure to provide increased resources during the July and August population increase View source Unavailability of reliable air support in North West Wales during overnight hours View source Insufficient planning for recruitment and retention of local Community First Responders View source Unreliable communication for contacting Community First Responders in remote and/or rural areas View source See 2 more concerns
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
Jasmine Ruby Lapsley · 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 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.
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 NHS Wales Joint Commissioning Committee; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective rota system for consistent Community First Responder cover
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” 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 NHS Wales Joint Commissioning Committee; that does not assign responsibility.
PFD Monitor interpretation Failure to provide increased resources during the July and August population increase
Wider context from the report “(4) The population of many rural and remote areas of North West Wales increases significantly during the months of July and August. WAST currently do not provide increased resources during these two months to cope with this increase in population . WAST should review their planning for effective allocation of resources to ensure the safety of this population during the months of July and August.
” 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 NHS Wales Joint Commissioning Committee; that does not assign responsibility.
PFD Monitor interpretation Unavailability of reliable air support in North West Wales during overnight hours
Wider context from the report “(1) There is no reliable WAST Air Support in North West Wales during the hours of 20.00 hours and 07.00 hours , those being the hours not covered by Wales Air Ambulance or the recently introduced Emergency Medical Retrieval Teams. WAST should review this gap in air support which is an essential asset in accessing, treating and retrieving critically ill or injured patients, particularly in remote and/or rural areas .
” 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 NHS Wales Joint Commissioning Committee; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning for recruitment and retention of local Community First Responders
Wider context from the report “(3) Given the difficulties in ambulances arriving at many rural and/or remote areas in North West Wales it is essential that there are sufficient local Community First Responders to arrive promptly at the casualty and provide essential treatment preserving life until an ambulance arrives . WAST should review the planning for the recruitment and retention of Community First Responders .
” 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 NHS Wales Joint Commissioning Committee; that does not assign responsibility.
PFD Monitor interpretation Unreliable communication for contacting Community First Responders in remote and/or rural areas
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent . WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” Open source report
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Addressed to Emergency Ambulance Services Committee, now represented here by NHS Wales Joint Commissioning Committee.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations