5 Feb 2026 Della Bridget CALVEY · Prevention of Future Deaths report Gwent
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Concerns raised 1 Unsafe downgrading of NEWS scores for all patients with COPD when baseline oxygen saturations are unknown View source
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Della Bridget CALVEY · 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
Della Bridget Calvey developed a urinary tract infection, deteriorated with confusion, dehydration and a raised NEWS score, and died at home from overwhelming sepsis caused by the infection. The inquest found that she should have been admitted to hospital but could not determine that admission would have prevented her death. The principal concern was the downgrading of NEWS scores for patients with COPD when baseline oxygen saturations were unknown, and the need for more robust clinical assessments.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe downgrading of NEWS scores for all patients with COPD when baseline oxygen saturations are unknown
Wider context from the report “The totality of the evidence indicated that it was not unusual for NEWS scores to be downgraded if a patient had COPD, even when their baseline saturations were not known . The rationale being “COPD sufferers often have lower oxygen saturation levels”. Whilst this may be true, applying this to all COPD sufferers, I consider to be an unsafe practice .
1. Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit)
2. What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.
” Open source report
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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 Using NEWS scale 2 for COPD patients at risk of hypercapnic respiratory failure is appropriate recognition, not downgrading.
Verbatim wording from the response ““Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit).”” Source location 2026-0063 - Response from Welsh Ambulance Service NHS Trust
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PFD Monitor interpretation No further action is considered necessary beyond the organisational learning already shared.
Verbatim wording from the response “With regard to “What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.”” Source location 2026-0063 - Response from Welsh Ambulance Service NHS Trust
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Concerns raised 2 Unavailability of emergency ambulance resources View source Delays in emergency ambulance response times View source
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Heather Louise Parkhill · 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
Heather Louise Parkhill died at home on 8 April 2025 after more than fifteen hours had elapsed since the first 999 call for assistance. Multiple calls did not result in an ambulance response because of resource issues, and an earlier response was considered likely to have prevented the death. The principal concerns were persistent ambulance resource shortages and delays in emergency response, with the report stating that lives continued to be put at risk.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of emergency ambulance resources
Wider context from the report “Category of Concern – Emergency Services Related Death
For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however problems regarding the unavailability of resources persist . I have a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue to be lost as a result of this problem.
Despite all of the multi-agency efforts to improve the availability of resources and hence response times, nothing appears to change I therefore remain concerned that lives continue to be at risk
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency ambulance response times
Wider context from the report “Category of Concern – Emergency Services Related Death
For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however problems regarding the unavailability of resources persist. I have a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue to be lost as a result of this problem.
Despite all of the multi-agency efforts to improve the availability of resources and hence response times , nothing appears to change I therefore remain concerned that lives continue to be at risk
” 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 Introduce purple and red emergency call categories for suspected cardiac or respiratory arrest and patients at high risk of arrest.
Verbatim wording from the response “Two new categories of call were initially introduced in July – a new purple category for people suffering a suspected cardiac and respiratory arrest and the red category for people at high risk of cardiac and respiratory arrest, including where this is a result of injury or illness.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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PFD Monitor interpretation Increase ambulance resources by completing roster changes and improving attendance levels.
Verbatim wording from the response “The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer more treatment at home or outside hospital in partnership with Health Board colleagues.
Verbatim wording from the response “The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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PFD Monitor interpretation Implement the Welsh emergency ambulance performance framework to provide clinically driven, outcome-focused responses.
Verbatim wording from the response “In July 2025, a new emergency ambulance performance framework was introduced in Wales, supporting a move away from time-based targets towards a more clinically driven, outcome-focused approach, with an emphasis on responding quickly to people with time-sensitive conditions.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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PFD Monitor interpretation Increase remote clinical support to prioritise available resources and improve safety-netting during significant pressures.
Verbatim wording from the response “The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit 28 clinical advisers to support rapid 999-call screening and appropriate first responses.
Verbatim wording from the response “As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an orange time-sensitive response category following clinical review of amber and green calls.
Verbatim wording from the response “The next phase of the framework was introduced in December, following a clinical review of the amber and green categories of call. A new orange – time-sensitive response category was introduced. This was designed to ensure people with conditions such as suspected stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact centres to receive a faster, more appropriate ambulance response, and rapid transport to specialist care.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply rapid clinical screening to non-purple and non-red 999 calls to tailor responses to patient needs.
Verbatim wording from the response “As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test and evaluate the emergency response framework and its broader patient-outcome and experience measurements over 12 months.
Verbatim wording from the response “The new framework also increases opportunities to better understand patient outcomes and experience by broadening measurement beyond initial response times to include more clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer insight into the timeliness and quality of care delivered to patients with serious and time-sensitive conditions, including stroke, to drive quality improvement.” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance staff knowledge, skills, competencies and available alternatives to minimise unnecessary hospital transport.
Verbatim wording from the response “The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:” Source location 2026-0050 - Response from Welsh Ambulance Services University NHS Trust
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Concerns raised 1 Failure of the MPDS system to remain fit for purpose for response prioritisation View source
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AI-generated summary
Shirley Ann Hughes · 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
Shirley Ann Hughes collapsed at home on 1 June 2024 and, because no ambulance was available, waited more than fifteen hours on the floor before treatment and hospital admission. The principal concern was whether the Medical Priority Dispatch System remained fit for purpose amid ambulance resource pressures, with the coroner concerned that lives were being put at risk.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the MPDS system to remain fit for purpose for response prioritisation
Wider context from the report “For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however on every occasion when evidence is presented at inquests, I am reminded that calls are prioritised using the Medical Priority Dispatch System (MPDS) by which a code is generated and that this is then matched to a response priority to provide an indication as to the most appropriate resource to respond.
At the inquest of Mrs Hughes, I was advised that MPDS was introduced in 2015 and at that time it was envisaged that an amber 1 priority call would be responded to in 20 minutes, however it was clearly the case that the multifactorial issues which prevail today were not envisaged at that time and that as a consequence this raises questions as to whether the MPDS system remains fit for purposes .
As a result of this evidence, I am concerned that lives are being put at risk.
” 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 Use the deployed Emergency Communication Nurse System and Call Priority Streaming System to support the Trust’s clinical and call-prioritisation strategy.
Verbatim wording from the response “In the absence of NHS Pathways or MPDS, it would require significant inhouse development to produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also deployed Emergency Communication Nurse System (ECNS) and Call Priority Streaming System (CPSS), both of which support our strategic direction. These are from the same provider as MPDS. There are a number of advantages presenting themselves, which is the potential synergies between MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 and 111 contacts).” Source location Response from Welsh Ambulance Services University NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed new clinical roles in control rooms to triage 999 calls earlier and support better care decisions.
Verbatim wording from the response “▪ As part of our plans for winter we are embedding new clinical roles in our control rooms to proactively triage 999 calls earlier in the call cycle. By using clinical expertise, it enables more effective clinical decisions regarding the best care to meet the patient’s needs.” Source location Response from Welsh Ambulance Services University NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developing an alternative call-prioritisation system would require significant in-house work beyond the Trust’s capacity and capability.
Verbatim wording from the response “In the absence of NHS Pathways or MPDS, it would require significant inhouse development to produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also deployed Emergency Communication Nurse System (ECNS) and Call Priority Streaming System (CPSS), both of which support our strategic direction. These are from the same provider as MPDS. There are a number of advantages presenting themselves, which is the potential synergies between MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 and 111 contacts).” Source location Response from Welsh Ambulance Services University NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MPDS remains the best available call-prioritisation product for the Trust, supported by linked ECNS and CPSS systems.
Verbatim wording from the response “To the Trust’s knowledge, MPDS and NHS Pathways are the only available products, worldwide. NHS Pathways is only used in England. In comparison to MPDS, NHS Pathways has a very small group of users, and the number of patients triaged using this tool versus MPDS is very small.” Source location Response from Welsh Ambulance Services University NHS Trust
Open published response
Concerns raised 2 Delays in responding to Amber 1 emergency calls View source Unavailability of ambulances due to prolonged waits to offload patients at hospitals View source
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AI-generated summary
Peter Parker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to Amber 1 emergency calls
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances due to prolonged waits to offload patients at hospitals
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with commissioners, health boards and system partners to improve access to local care pathways and develop safe referral options.
Verbatim wording from the response “◦ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department.
◦ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care” Source location Response from WELSH AMBULANCE SERVICE NHS TRUST
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a broader range of face-to-face response options to support safe treatment at home and avoid unnecessary hospital conveyance.
Verbatim wording from the response “◦ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department.
◦ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care” Source location Response from WELSH AMBULANCE SERVICE NHS TRUST
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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 Embed new clinical roles in control rooms to triage 999 calls earlier and support more effective care decisions.
Verbatim wording from the response “▪ As part of our plans for winter we are embedding new clinical roles in our control rooms to proactively triage 999 calls earlier in the call cycle. By using clinical expertise, it enables more effective clinical decisions regarding the best care to meet the patient’s needs.” Source location Response from WELSH AMBULANCE SERVICE NHS TRUST
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No additional actions are proposed because existing plans and measures already address ambulance response risks.
Verbatim wording from the response “The Trust does not propose to take any additional, or new, actions specifically in relation to this Preventing Future Deaths report because of existing plans already being enacted. Whilst we recognise that this may appear insensitive given the loss Mr Parker’s family have experienced and in light of the risks you raise with us, we hope to provide assurance that the Trust already recognised the risks and pressures within Urgent and Emergency care pathways and is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from its commissioners through its commissioning body, the JCC, Welsh Government, the wider NHS and Local Government to ensure appropriate clinical risk management across the urgent and emergency care pathway to release resources with the Trust.” Source location Response from WELSH AMBULANCE SERVICE NHS TRUST
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emergency department handover delays reduce ambulance capacity and constrain the Trust’s ability to provide timely responses despite internal improvement measures.
Verbatim wording from the response “We hope that this information supports our position that we are doing everything within our sphere of control and influence to deliver more timely, safer care however we are acutely aware of the limitations of our actions within the wider health and care landscape of extreme pressures across Urgent and Emergency Care systems. The number of hours' worth of Trust emergency ambulance production lost per month due to long waits at emergency departments is consistently reaching the 25,000 to 30,000 hours mark. This equates to approximately 20 per cent to 25 per cent of our entire fleet capacity every month as a result of the pressure right across the urgent and emergency care system. This issue remains the highest influencing factor on our ability to provide timely responses, far above and beyond the incremental improvement measures being taken internally by the Trust.” Source location Response from WELSH AMBULANCE SERVICE NHS TRUST
Open published response
Concerns raised 1 Failure of paramedics and ambulance crew to carry flumazenil for acute emergencies View source
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AI-generated summary
STEFAN WALKER · 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
STEFAN WALKER was a detained patient receiving inpatient psychiatric treatment when he became unresponsive in his room on 29 June 2020 after concerns that he had consumed illicit substances and was physically unwell. The inquest concluded that his death was drug related, with the medical cause given as buprenorphine and flualprazolam intoxication and cardiac enlargement. The principal concern was that paramedics did not carry flumazenil, which might be needed in acute circumstances involving certain benzodiazepines.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of paramedics and ambulance crew to carry flumazenil for acute emergencies
Wider context from the report “(1) I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry naloxone). The availability of flumazenil was hampered in this case because STEFAN was on an acute psychiatric ward where the said antagonist was being kept and could be prescribed by the ward pharmacist and administered by the doctors (with the support paramedics when they arrived).
(2) I am concerned that there may be other acute circumstances when the use of this particular antagonist (flumazenil) could make a difference (say in the case of the collapse of person on the street or otherwise in the community) but will not be available since paramedics do not it .
(3) I and the jury heard no evidence as to why naloxone is carried, but other antagonists (such as flumazenil) not.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Authorise trained paramedics to carry and use flumazenil under a patient group directive only to reverse benzodiazepines they administered.
Verbatim wording from the response “Some of our Welsh Ambulance Service paramedics do carry flumazenil and may utilise it under a patient group directive (PGD) authority. But this use is specifically only for the emergency reversal of benzodiazepines which they have administered, so this only applies to paramedics who are trained and authorised to use advanced sedative pain-relieving drug options. These paramedics however can (and should) only use flumazenil in this specific context, and the PGD is explicit that it should not be used in the context of other suspected benzodiazepine overdose for the reasons outlined above.” Source location Response from Welsh Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Flumazenil should not be carried for suspected benzodiazepine overdose because its use is hazardous and contrary to current clinical guidance.
Verbatim wording from the response “There are very robust clinical reasons as to why flumazenil cannot and should not be considered in the same way. While flumazenil does reverse the effects of benzodiazepines, its use for overdosage of benzodiazepines (and in particular overdose in the context of multiple drugs including benzodiazepines) is controversial and potentially very hazardous.” Source location Response from Welsh Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing advanced airway techniques and supportive care strategies are considered more appropriate for managing benzodiazepine overdose.
Verbatim wording from the response “Hopefully the explanation I have provided above will reassure you that flumazenil should not be used in this context based on all current clinical guidelines. Ambulance personnel are trained in advanced airway techniques and other supportive care strategies which are more appropriate for the management of benzodiazepine overdose.” Source location Response from Welsh Ambulance Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use of flumazenil outside its licensed indication cannot legally be authorised for paramedic use.
Verbatim wording from the response “The UK licenced indication for flumazenil is the “reversal of sedative effects of benzodiazepines in anaesthesia and clinical procedures”. Any use in other circumstances would be outside of the scope of the UK product licence and would not be something we could legally authorise for paramedic use.” Source location Response from Welsh Ambulance Service
Open published response
Concerns raised 2 Delays in offloading patients into hospital View source Delays in getting ambulances to vulnerable patients 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
Jean 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
Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.
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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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in offloading patients into hospital
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie. I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be offloaded into hospital . The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes ,
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in getting ambulances to vulnerable patients
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie . I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie . That pressure sore was exacerbated by a further long wait to be offloaded into hospital. The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes,
” Open source report
7 Feb 2024 Brian JAMES · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to maintain regular welfare calls and reassess delayed ambulance responses View source Failure to ensure callers understand when to call back about deterioration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian JAMES · 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
Brian JAMES, aged 91, suffered a cerebral haemorrhage after falling out of bed at home and died in hospital on 1 November 2021. There was an approximately nine-hour delay before the ambulance arrived. Concerns included callers not understanding when to call back during delayed ambulance responses and the risk that insufficient welfare calls could result in missed reassessment and regrading of the response.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain regular welfare calls and reassess delayed ambulance responses
Wider context from the report “(1) A script used by Operators within WAST as part of the Clinical Safety Plan inform callers not to call back for an estimated time of arrival of the ambulance. They are told to only call back if there is a deterioration in the patient’s condition.
(2) During periods of a delayed response from an ambulance, WAST best practice is for an Operator to maintain regular contact with callers to assess any change in their condition. During periods of excessive demand, it is considered that this is not always achievable , and therefore Welfare calls are prioritised to callers considered vulnerable.
(3) There may be a risk that callers do not understand the instruction to only call back if there is a deterioration, and/or may not recognise a deterioration, and feel they cannot call WAST again. There is a further risk that unless regular welfare calls are made during periods of delayed response, there is a missed opportunity to properly re-assess and re-grade the response to a call by WAST.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure callers understand when to call back about deterioration
Wider context from the report “(1) A script used by Operators within WAST as part of the Clinical Safety Plan inform callers not to call back for an estimated time of arrival of the ambulance. They are told to only call back if there is a deterioration in the patient’s condition.
(2) During periods of a delayed response from an ambulance, WAST best practice is for an Operator to maintain regular contact with callers to assess any change in their condition. During periods of excessive demand, it is considered that this is not always achievable, and therefore Welfare calls are prioritised to callers considered vulnerable.
(3) There may be a risk that callers do not understand the instruction to only call back if there is a deterioration, and/or may not recognise a deterioration, and feel they cannot call WAST again. There is a further risk that unless regular welfare calls are made during periods of delayed response, there is a missed opportunity to properly re-assess and re-grade the response to a call by WAST.
” 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 Revise the Emergency Medical Dispatcher escalation script to remove the instruction not to call back for an ambulance arrival estimate and remind callers to call back if circumstances worsen.
Verbatim wording from the response “The Clinical Safety Plan is currently being reviewed. As part of this review, the Emergency Medical Dispatcher call script in escalation is being changed and the instruction not to call back to check the estimated arrival time of the ambulance is being removed. Instead, the caller will be reminded to call back if anything changes/they get worse. The review is currently in progress and the document needs to go through the relevant governance for internal approvals.” Source location Response from Welsh Ambulance Service
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 Explore technology-enabled methods for providing welfare calls to patients waiting in the community, informed by processes used by other UK ambulance trusts.
Verbatim wording from the response “Emergency Medical Service Coordination is currently in the process of undergoing a restructure which will include a support role for dispatch. Whilst job descriptions, roles and responsibilities are yet to be confirmed, undertaking welfare calls will form part of the day-to-day responsibilities of this role. Additionally, the Trust is exploring new ways using technology to ensure the provision of welfare calls to patients waiting in the community and is liaising with other UK ambulance trusts to understand if there are any different processes in place which would be suitable for this Trust’s development and use.” Source location Response from Welsh Ambulance Service
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 Establish a dispatch support role whose day-to-day responsibilities include undertaking welfare calls for patients waiting prolonged periods for ambulance responses.
Verbatim wording from the response “Emergency Medical Service Coordination is currently in the process of undergoing a restructure which will include a support role for dispatch. Whilst job descriptions, roles and responsibilities are yet to be confirmed, undertaking welfare calls will form part of the day-to-day responsibilities of this role. Additionally, the Trust is exploring new ways using technology to ensure the provision of welfare calls to patients waiting in the community and is liaising with other UK ambulance trusts to understand if there are any different processes in place which would be suitable for this Trust’s development and use.” Source location Response from Welsh Ambulance Service
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 High demand and limited capacity prevent regular welfare calls while emergency calls are prioritised.
Verbatim wording from the response “The Managing Delayed Response Standard Operating Procedure sets out a process to undertake welfare calls for those patients who are waiting a prolonged time for a response due to high demand. It is identified that it is best practice to maintain regular contact with patients who are experiencing a protracted response, but it is recognised that there may be limited capacity to undertake welfare calls due to high demand. Call takers’ priority is to take incoming emergency calls to identify patients who are sickest to ensure an appropriate response. Where capacity issues mean that a welfare call cannot be undertaken, this is documented within the incident. Callers are instructed to call back if anything changes/they get worse as covered in the above point.” Source location Response from Welsh Ambulance Service
Open published response
15 Nov 2023 Lynda BLACKMORE · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital 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
Lynda BLACKMORE · 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
Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital
Wider context from the report “My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital . As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016 .
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
” Open source report
Concerns raised 1 Failure of handlers to follow the appropriate MPDS pathway for providing clinically beneficial advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rashdah Waseem Begum Bhatti · 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
Rashdah Waseem Begum Bhatti died at home after haemorrhaging from varicose veins while taking anticoagulants. Ambulance assistance was delayed for several hours, and concern was raised that call handlers failed to provide clinically beneficial advice available within the Medical Priority Dispatch System and that reminders to staff might not reduce such errors.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of handlers to follow the appropriate MPDS pathway for providing clinically beneficial advice
Wider context from the report “The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object”
Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased.
Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway .
” 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 Undertake improvement actions identified through the further targeted audit.
Verbatim wording from the response “During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.” Source location Response from Welsh Ambulance Services NHS Trust
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 Issue all call handlers a reminder about correctly using Post-Dispatch Instructions.
Verbatim wording from the response “During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.” Source location Response from Welsh Ambulance Services NHS Trust
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 Complete a focused audit of protocol 21 calls and Post-Dispatch Instructions.
Verbatim wording from the response “During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.” Source location Response from Welsh Ambulance Services NHS Trust
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 Undertake a further targeted audit of protocol 21 calls to verify correct delivery of Post-Dispatch Instructions.
Verbatim wording from the response “During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
Concerns raised 8 Failure to communicate nil-by-mouth status to visitors View source Failure to document the rationale for oxygen administration and clinician discussion View source Insufficient space for nursing care and pressure-area assessment View source Insufficient nursing and clinical staffing capacity View source Lack of written nursing documentation of patient care View source Delays in allocation of hospital beds from the Emergency Department View source Delays in entry into hospital from ambulance arrival View source Failure to complete or communicate required repeat blood tests View source See 5 more concerns
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
Philip Hawkins · 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
Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate nil-by-mouth status to visitors
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the rationale for oxygen administration and clinician discussion
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician .
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient space for nursing care and pressure-area assessment
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas .
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing and clinical staffing capacity
Wider context from the report “Staffing
9. There were insufficient nursing and clinical staff to attend to the numbers of patients as outstanding nursing shifts went unfulfilled on the nursing rota .
10. Due to the presenting circumstances, staff were unable to fulfil their role in caring for Mr Hawkins.
11. Specifically, I am concerned as to the wait and delay Mr Hawkins had to endure to enter hospital and the same in respect of being provided with a bed; the inability of staff to tend to him; the lack of available staff and the lack of written record of assessment and treatment.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written nursing documentation of patient care
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23 .
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation of hospital beds from the Emergency Department
Wider context from the report “Entry into Hospital and Delay to bed allocation
1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED).
2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day.
3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23 .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in entry into hospital from ambulance arrival
Wider context from the report “Entry into Hospital and Delay to bed allocation
1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED) .
2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day.
3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or communicate required repeat blood tests
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians .
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” Open source report
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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 Welsh Ambulance Services NHS Trust; 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 2 Insufficient ambulance resource availability for timely attendance View source Delays in ambulance handover across BCUHB sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Colin Strachan · 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
David Strachan developed sudden chest pain, vomiting, clamminess and shortness of breath at home on 15 March 2022. After multiple 999 calls, an ambulance and paramedics arrived only later that morning; he was diagnosed with an ST elevation myocardial infarction, transferred to hospital and died on 16 March 2022. The principal concern was delayed ambulance attendance associated with resource pressures and handover delays, with the report stating that significant concerns remained.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance resource availability for timely attendance
Wider context from the report “The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.
The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limited. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover across BCUHB sites
Wider context from the report “The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites .
The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limited . Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.
” 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 Continue monitoring, updating and presenting the Reducing Patient Harm Action Plan to the Trust Board.
Verbatim wording from the response “The Trust has previously provided evidence to coroners pan-Wales regarding the actions that have been taken in order to reduce the lost hours and improve our response times for patients waiting in the community. In my response to you regarding Mrs. Glynis Roberts, I shared a copy of the Reducing Patient Harm Action Plan that had been tabled in our Trust Board meeting.” Source location Response from Welsh Ambulance Services NHS Trust
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 Revisit the Clinical Safety Plan to address patient-safety risks when ambulances are unavailable.
Verbatim wording from the response “when ambulances are unavailable. Additionally, we have shared with you the measures that are currently in place such as the Clinical Safety Plan and the Regional Escalation Action Plan. I will not repeat those within this response to you, however, the Clinical Safety Plan was revisited in December 2022 and I attach at appendix 1, a copy of the latest plan.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
20 Jan 2023 Dorothy Anne Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need View source Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines View source Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness View source Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Anne 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
Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need
Wider context from the report “2. The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines
Wider context from the report “3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited . However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
Wider context from the report “4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed , under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe
Wider context from the report “1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent , where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients .
” 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 Conduct secondary triage of waiting patients, including Amber 1 calls, through the Clinical Support Desk to reassess or confirm priority.
Verbatim wording from the response “In the live environment, WAST regularly undertakes more detailed clinical assessments of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the correct priority for patients. This process, known as secondary triage or consultation is led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control room nurses, paramedics, advanced paramedics, and mental health practitioners.” Source location Response from Welsh Ambulance Services NHS Trust
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 Roll out the Physician Triage Assessment and Streaming model to additional health boards.
Verbatim wording from the response “WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.” Source location Response from Welsh Ambulance Services NHS Trust
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 Use welfare calls and Clinical Support Desk procedures to reassess waiting patients and upgrade calls when clinical conditions or prolonged waits warrant it.
Verbatim wording from the response “A copy of the CSP is attached for your reference and as you will see this provides details of when welfare calls should be made. These calls are made to reassess the patient’s clinical condition, if any changes are reported.” Source location Response from Welsh Ambulance Services NHS Trust
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 Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Verbatim wording from the response “To ensure that the Welsh Ambulance Services NHS Trust (WAST) maintains a clinically safe response to patients, regular reviews are undertaken of current Medical Priority Dispatch System (MPDS) code categorisation by the Clinical Priority Assessment Software (CPAS) group.” Source location Response from Welsh Ambulance Services NHS Trust
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 Operate the Physician Triage Assessment and Streaming model across three health boards using upgraded Computer Aided Dispatch tools.
Verbatim wording from the response “WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.” Source location Response from Welsh Ambulance Services NHS Trust
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 Expand Clinical Support Desk capacity, employ mental health practitioners, and implement clinical decision-support software for detailed patient assessment.
Verbatim wording from the response “consultation. WAST has recently invested in the CSD by near doubling its establishment, employing mental health practitioners, and by implementing a new innovative clinical decision support system to support the more detailed clinical assessment of patients.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
9 Nov 2022 Maria Immocalata Whale · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure of the 999 emergency triage questionnaire to adequately measure clinical gravity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maria Immocalata Whale · 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
Maria Immocalata Whale, aged 67, suffered a fatal pelvic haemorrhage and abdominal wall haematoma at home on 29 June 2021 after experiencing increasing abdominal pain. The report identifies concerns about the inability of the Out of Hours GP service to provide assistance, the delayed ambulance response, and emergency triage that did not adequately assess the gravity of her condition.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the 999 emergency triage questionnaire to adequately measure clinical gravity
Wider context from the report “(2) During the repeated calls to the 999 Emergency Services, ████████ was advised the following:
i) there were no resources available;
ii) Mrs. Whale did not meet the criteria to have an elevated priority status; and
iii) when asked to define the degree of pain suffered on a scale of 1-10 Mrs. Whale (who was screaming in agony) responded “11”. ████████ stated in Court that the call responder concluded that if Mrs. Whale could scream then she was not a priority. Within an hour of this conversation Mrs. Whale had died without any emergency support and in agony.
████████ Clinical Director of Cardiff and Vale UHB Urgent Care Service confirmed in Court that the Out of Hours (OoH) GP service had two GPs on duty that night – one of whom was attending a patient while the other was assisting the triage nurses. It was also confirmed that for the period during which ████████ had called the OoH service, the numbers of calls were comparatively low.
Under oath, Dr. ████████ stated that the advice given to ████████ by the triage nurse was correct – either to take Mrs. Whale to hospital by taxi or call 999. He confirmed that the triage nurse had recognised Mrs. Whale was gravely ill. He disagreed that the second GP should have attended Mrs. Whale saying that the GP could neither have assisted with the diagnosis nor with accessing emergency transport to hospital by advising the 999 service of the urgency of the need for hospital admission. Pain relief provision by the OoH GP service was not mentioned.
Dr. ████████ was adamant that an OoH GP would have been unable to expedite Mrs. Whale’s access to hospital even though the gravity of her condition was accepted. He was similarly adamant that a GP attending Mrs. Whale would not have been able to communicate the gravity of her condition to the emergency services any better than a lay person - in this case the distressed husband. Again, provision of pain relief was not mentioned.
The 999 Emergency Service triage patients for priority depending on the response provided by a person close at hand to the patient, to a series of scripted questions. The Welsh Ambulance Service Trust has advised the following:
• Red calls are the highest clinical priority and are deemed immediately life threatening e.g. cardiac arrest;
• Amber 1 calls have a high clinical priority and are still considered a life threatening emergency e.g. chest pain;
• Amber 2 calls have urgent clinical priority, are serious but not considered immediately life threatening, for example diabetic problems; and
• Green calls are not considered to have urgent clinical priority and are not considered serious or life threatening.
████████ in responding to these questions advised his wife was not a priority. Clearly, the triage questionnaire did not adequately measure the gravity of Mrs. Whale’s condition , as within two hours of being graded a ‘non-priority’ she was declared life extinct.
” Open source report
×
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 prioritisation questions are not considered inappropriate; patient harm is attributed primarily to the Trust’s inability to respond promptly.
Verbatim wording from the response “At this time the Trust does not intend to adjust the prioritisation questioning, as the issue is not so much the appropriateness of the questions but rather the harm caused by the Trust not being able to respond in a timely manner.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
24 Oct 2022 Glenys Roberts · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 3 Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability View source Delays in reviewing and acting on intra-hospital transfers View source Failure of the vascular emergency transfer pathway to provide direct hospital admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glenys 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
Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability
Wider context from the report “3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing and acting on intra-hospital transfers
Wider context from the report “1. Review of and action relating to intra hospital transfers has been too slow
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the vascular emergency transfer pathway to provide direct hospital admission
Wider context from the report “2. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow
” 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 Work fortnightly with BCU Health Board and NCCU through an action plan to improve ambulance resource availability for intra-hospital transfers.
Verbatim wording from the response “The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers. A key issue is the ongoing lack of ambulance availability due to our resources being delayed at hospitals. Therefore, the Trust has offered to develop a longer-term solution for intra hospital transfers which could employ dedicated resources to move patients in a timely manner. As the Trust is a commissioned organisation there is high reliance on BCU Health Board and NCCU commissioning additional services. We have evidence of successful deployment elsewhere in Wales, namely the Aneurin Bevan University Health Board, where the health board commissioned dedicated services.” Source location Response from Welsh Ambulance Services NHS Trust
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 Operate the implemented vascular bypass protocol across the South East Wales Vascular network for conditions including abdominal aortic aneurysm and ischaemic limb.
Verbatim wording from the response “The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines. This includes a range of conditions including abdominal aortic aneurysms (AAA) and ischemic limb, and has been implemented in the South East Wales Vascular network. BCU Health Board Vascular Network has accepted part of this pathway, the immediate bypass for ischemic limb to Ysbyty Glan Clwyd, but not for AAA. The Trust is currently finalising the pathway with BCU Health Board for implementation.” Source location Response from Welsh Ambulance Services NHS Trust
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 Develop and commission a longer-term intra-hospital transfer model, including potential dedicated transfer resources, following demand validation and cross-organisation collaboration.
Verbatim wording from the response “The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers. A key issue is the ongoing lack of ambulance availability due to our resources being delayed at hospitals. Therefore, the Trust has offered to develop a longer-term solution for intra hospital transfers which could employ dedicated resources to move patients in a timely manner. As the Trust is a commissioned organisation there is high reliance on BCU Health Board and NCCU commissioning additional services. We have evidence of successful deployment elsewhere in Wales, namely the Aneurin Bevan University Health Board, where the health board commissioned dedicated services.” Source location Response from Welsh Ambulance Services NHS Trust
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 Finalise and implement the vascular emergency bypass pathway with BCU Health Board, including direct hospital admission arrangements and operational contact and destination details.
Verbatim wording from the response “The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines. This includes a range of conditions including abdominal aortic aneurysms (AAA) and ischemic limb, and has been implemented in the South East Wales Vascular network. BCU Health Board Vascular Network has accepted part of this pathway, the immediate bypass for ischemic limb to Ysbyty Glan Clwyd, but not for AAA. The Trust is currently finalising the pathway with BCU Health Board for implementation.” Source location Response from Welsh Ambulance Services NHS Trust
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 Maintain the Handover Improvement Plan with BCU Health Board and NCCU, using integrated commissioning action plans and fortnightly meetings to improve system flow and ambulance availability.
Verbatim wording from the response “The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU. Going forward these meetings will be the host for integrated commissioning action plans, part of the refreshed Emergency Medical Services Commissioning Framework approved by Emergency Ambulance Services Committee.” Source location Response from Welsh Ambulance Services NHS Trust
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 vascular pathway cannot be released for immediate use until the Health Board provides a contact number and destination.
Verbatim wording from the response “A draft document has been shared with BCU Health Board on 22 November 2022 to provide some BCU Health Board specific demographic and service delivery information, along with terminology although this can be considered non-essential with regard to implementation of the pathway and will not delay the release of this document to staff. The Trust is still waiting for a direct dial contact number that can be added to Consultant Connect and a destination for crews when patients have been accepted through this pathway. Once we have the information from the Health Board the information can be released for immediate use.” Source location Response from Welsh Ambulance Services NHS Trust
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 Additional intra-hospital transfer services depend on BCU Health Board and NCCU commissioning them.
Verbatim wording from the response “The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers. A key issue is the ongoing lack of ambulance availability due to our resources being delayed at hospitals. Therefore, the Trust has offered to develop a longer-term solution for intra hospital transfers which could employ dedicated resources to move patients in a timely manner. As the Trust is a commissioned organisation there is high reliance on BCU Health Board and NCCU commissioning additional services. We have evidence of successful deployment elsewhere in Wales, namely the Aneurin Bevan University Health Board, where the health board commissioned dedicated services.” Source location Response from Welsh Ambulance Services NHS Trust
Open published response
17 Jun 2022 Gwynne SAMUEL · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Delays in providing ambulances to patients assessed as serious Amber 2 cases View source Failure to account for the clinical ramifications of prolonged lying in elderly patients during ambulance categorisation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gwynne SAMUEL · 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
Gwynne Samuel, a 95-year-old man who lived alone, fell at home and waited approximately 12 hours for an ambulance before being taken to hospital. He developed an acute kidney injury attributed to the prolonged lie, which delayed hip surgery; he subsequently developed a chest infection and died from pneumonia. The principal concern was the ambulance response time for a patient categorised as Amber 2 and whether the clinical effects of a prolonged lie in an elderly person were adequately considered during categorisation.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing ambulances to patients assessed as serious Amber 2 cases
Wider context from the report “GS was an elderly gentleman who had suffered a significant fall. The time it took for an ambulance to arrive and convey him to hospital contributed to his death insofar that the development of an acute kidney injury, which compromised his treatment and general condition, was caused by a long lie.
A report obtained from WAST indicated that GS had been categorised as an Amber 2, which I understand is an urgent clinical priority considered serious but not life threatening.
Whilst I accept that there was no evidence that GS was in immediate peril, it would appear that the clinical ramifications of an elderly person lying for a long period of time are not taken into account during the categorisation process.
Whilst I heard evidence, and understand, the pressures on the ambulance service during the pandemic and the inability to release emergency ambulances due to congestion in hospital emergency departments, the inability to provide an ambulance to a patient determined to be in a serious condition (Amber 2) for 12 hours , puts lives in danger and, as in this case, may contribute to their death.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for the clinical ramifications of prolonged lying in elderly patients during ambulance categorisation
Wider context from the report “GS was an elderly gentleman who had suffered a significant fall. The time it took for an ambulance to arrive and convey him to hospital contributed to his death insofar that the development of an acute kidney injury, which compromised his treatment and general condition, was caused by a long lie.
A report obtained from WAST indicated that GS had been categorised as an Amber 2, which I understand is an urgent clinical priority considered serious but not life threatening.
Whilst I accept that there was no evidence that GS was in immediate peril, it would appear that the clinical ramifications of an elderly person lying for a long period of time are not taken into account during the categorisation process .
Whilst I heard evidence, and understand, the pressures on the ambulance service during the pandemic and the inability to release emergency ambulances due to congestion in hospital emergency departments, the inability to provide an ambulance to a patient determined to be in a serious condition (Amber 2) for 12 hours, puts lives in danger and, as in this case, may contribute to their death.
” 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 Use cohorting crews to offload patients delayed outside hospitals, releasing frontline vehicles for waiting community calls.
Verbatim wording from the response “To further mitigate the risk significant hospital delays are causing the service, cohorting crews provided by a private provider are being used to care for patients delayed outside Morriston and the Grange Hospitals while specific funding remains available.” Source location Response from Welsh Ambulance Services
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 Monitor the three new falls MPDS code suffixes and review data to consider recommendations on differentiated priorities.
Verbatim wording from the response “The recent update to ProQA (the system for monitoring data within MPDS) released on 10th May 2022 has split the MPDS code suffix relating to falls on the ground or floor and added time targets as below:” Source location Response from Welsh Ambulance Services
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 Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
Verbatim wording from the response “The Medical Prioritisation Dispatch System (MPDS) does not provide a determinant code based on age within Protocol 17 (falls) which would prevent a specific prioritisation change for elderly patients. The principal role of the Clinical Support Desk (CSD) Clinician is to provide additional clinical triage, advice and support to patients to ensure that they can access the most clinically appropriate care for their urgent and emergency healthcare needs, commonly known as Hear and Treat (H&T). In addition to this principal role, the CSD also undertake a range of other clinical functions in pursuance of maximising patient safety for those awaiting an emergency ambulance. This includes reviewing long waiting patients to maintain patient safety.” Source location Response from Welsh Ambulance Services
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 Review post-fall patient guidance and immobility risks through the Older Persons Improvement Group, then suggest improvements.
Verbatim wording from the response “This has been delayed due to high levels of escalation within the organisation. However, it will be essential to seek opportunities to increase the levels of utilisation of falls resources, ensuring we are able to maximise response capacity across Wales. The newly formed Older Persons Improvement Group (OPIG), will conduct a review of the guidance provided to patients following a fall, consider the risks associated immobility and will suggest possible improvements, as part of the newly formed group, due to meet in August 2022.” Source location Response from Welsh Ambulance Services
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 Use shorter-term forecasting and quarterly performance reports to develop mitigating action plans when performance is forecast below requirements.
Verbatim wording from the response “Seasonal planning including forecasting
As well as utilising the services of ORH in longer term demand and capacity modelling, the Trust also commissions services from Optima who use simulation models which can predict output performance based on a range of input assumptions.” Source location Response from Welsh Ambulance Services
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 Refer categorisation of elderly patients affected by prolonged immobility after falls to the Clinical Priority Software Advisory Group.
Verbatim wording from the response “The categorisation of elderly patients who suffer falls and are more likely be affected by the risks associated with lengthy periods of immobility, will be referred to the Trust’s Clinical Priority Software Advisory Group.” Source location Response from Welsh Ambulance Services
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 Operate the Clinical Safety Plan to dynamically prioritise patients with the most serious conditions when demand exceeds available resources.
Verbatim wording from the response “Clinical Safety Plan” Source location Response from Welsh Ambulance Services
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 Continually review and update dispatch guidance for falls and frailty responders.
Verbatim wording from the response “CSD clinicians have the ability to change the responding priority of an incident based on a secondary clinical assessment, this includes increasing the priority where the patient’s clinical acuity indicates this is appropriate. Dispatch guidelines regarding falls and frailty responders are continually reviewed and updated to ensure maximum utilisation of this valuable resource, part of the CSD role is to provide support to falls assistants following an initial assessment to ensure the correct outcome is reached.” Source location Response from Welsh Ambulance Services
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 Provide enhanced Clinical Desk capacity for targeted telephone advice to patients awaiting responses, including pressure-ulcer prevention and reduced immobility.
Verbatim wording from the response “Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.” Source location Response from Welsh Ambulance Services
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 Maintain unrestricted voluntary overtime availability for operational and clinical staff.
Verbatim wording from the response “Voluntary overtime remains available for all operational/clinical staff across the Trust without financial restriction and whilst uptake has reduced in recent months, largely as a result of the current workplace experience, we continue to see in excess of 5,000 hours per week being worked. Controls to restrict the overall spend on overtime may need to be introduced as the year proceeds should the financial position require it.” Source location Response from Welsh Ambulance Services
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 Operate the Operational Delivery Unit to monitor real-time performance inhibitors, maintain situational awareness and coordinate mitigation across the unscheduled-care system.
Verbatim wording from the response “The Operational Delivery Unit (ODU) acts as a central hub providing coordination for the Welsh Unscheduled Care System with a link between the Trust, Welsh Government, and all the Health Boards through a system-wide view.” Source location Response from Welsh Ambulance Services
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 Recruit and train additional staff to increase operational response capacity across Wales.
Verbatim wording from the response “The ORH concluded that bridging the gap would require an investment of 263 staff on a full time equivalent (FTE) basis across Wales. The Emergency Ambulance Services Committee (EASC) agreed to invest in the Trust, over a two year period – 2020/21 and 2021/22, and close the “relief gap”, while it was agreed re-rostering would help improve the alignment and mix of resources allied to patient demand.” Source location Response from Welsh Ambulance Services
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 and submit the Transition Plan seeking investment and setting out internal efficiency and delivery-model changes.
Verbatim wording from the response “The Trust is committed to doing all that it can to reduce clinical risk, improve patient care and outcomes, ensuring that patients get the right service, in the right place, every time. The data in support of this statement shows that there is much more to do, with some actions within the Trust’s control, and many which are outside of its control.” Source location Response from Welsh Ambulance Services
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement new demand-aligned rosters across Wales, incorporating the identified additional single-staffed-car capacity.
Verbatim wording from the response “In the same time period, the Trust agreed to take steps to reduce abstractions due to sickness absence, to increase ‘hear and treat’ rates (where patients are triaged and given advice rather than deploying an ambulance) to 10.2% and to implement new rosters across Wales.” Source location Response from Welsh Ambulance Services
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 New rosters will initially retain a relief gap because commissioners have not provided additional resources for 2022/23.
Verbatim wording from the response “The four working parties have now concluded, and it is anticipated that the new rosters will be implemented between September and November 2022. As outlined above, by aligning rosters more closely with demand patterns, this will have the equivalent impact of an increase of 72 WTE.” Source location Response from Welsh Ambulance Services
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 Current demand pressures mean the Trust is unlikely to send responses or act differently within the newly assigned MPDS time targets.
Verbatim wording from the response “There have been discussions at the National Ambulance Service Medical Executive Directors Group (NASMED) as to whether there should be further MPDS code suffixes for falls longer than two hours. NASMED has also highlighted the issue relating to calls just inside a time target window and calls where there is no further contact as the call does not automatically change if the call falls outside the MPDS code suffix window therefore there will be some patients disadvantaged for not calling back.” Source location Response from Welsh Ambulance Services
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 Trust cannot insist on discrete system actions; substantial resourcing and policy direction depend on Welsh Government and other system partners.
Verbatim wording from the response “While significant collaborative work continues to be undertaken on these issues, there is little that the ambulance service can fundamentally do to insist on discrete actions, beyond lobbying and highlighting the very significant patient safety concerns which arise, particularly from extended waits outside hospitals, which inevitably also result in excessive waits for those patients awaiting help in the community.” Source location Response from Welsh Ambulance Services
Open published response
Concerns raised 3 Risk of deaths associated with delayed ambulance transfer or unavailability View source Failure to make ambulance resources available for lower-priority or later-registered calls View source Delays in ambulance handovers across BCUHB sites 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
Raymond Gillespie · 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
Raymond Gillespie, a care home resident with multiple comorbidities, suffered an unwitnessed fall on 8 October 2021 and waited almost 15 hours for a paramedic response after calls to the Welsh Ambulance Service Trust. The report identified delays caused by resource availability and ambulance handover delays, with a continuing risk of future deaths or harm while patients await transfer or community paramedic assistance.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of deaths associated with delayed ambulance transfer or unavailability
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital .
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make ambulance resources available for lower-priority or later-registered calls
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handovers across BCUHB sites
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites . A total of 131.1 hours were lost in delay of handovers on 9 October 2021 .
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” Open source report
4 Feb 2022 Sarah Marie GILBERT-JONES · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure of clinical review to use toxicology information to identify time-critical treatment and upgrade response View source Failure of call-processing protocols to incorporate overdose information into response categorisation View source Inconsistent response coding and categorisation leading to unreliable vehicle dispatch decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Marie GILBERT-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
Sarah Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical review to use toxicology information to identify time-critical treatment and upgrade response
Wider context from the report “(2) There appeared to be an opportunity shortly following the initial categorisation of the response, by a clinical floor walker, to upgrade to a code/categorisation which would likely have led to a swifter response , but an under-appreciation, or otherwise, of the then time critical treatment window open to the deceased . I was informed in evidence that the clinical floor walker would have had access to TOXBASE via the Clinical Support Desk at that time, & had that been accessed & information promptly secured regarding the treatment indicated, this would have alerted the clinician to the need for an acute emergency response . This was subsequently undertaken by the attending paramedic (albeit not via TOXBASE) some hours later, & who immediately after having accessed the treatments for massive ████████ overdose, appreciated that the deceased was a time sensitive patient & to convey to the emergency department with all haste.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of call-processing protocols to incorporate overdose information into response categorisation
Wider context from the report “(1) When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it was accepted that he explicitly indicated to the Call Handler that the deceased had taken an overdose of, inter alia, ████████ tablets. Based upon that, & answers to other questions posed by the call handler, the call handler selected a protocol which did not appear to require this crucial piece of information to be either recorded within it, or to form part of the material which led to the categorisation of the call for the purposes of determining the appropriate response. In short, it led to a categorisation which could only loosely provide a response (based upon the level of demand that evening) estimate of around 3 hours . The concern here is that treatment for a massive ████████ overdose is time critical, & the processing of the call did not appear to accurately reflect the peril the deceased was then in, nor the importance of providing an acute emergency response .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent response coding and categorisation leading to unreliable vehicle dispatch decisions
Wider context from the report “(3) Following the second call to Clinical Contact Centre at 23.48 on 28.10.20, there were somewhat bewilderingly complex, & inconsistent categorisations of the code for response which appeared to lead to response vehicles being dispatched or stood down , whilst the patient remained in need of time sensitive treatment by way of transfer to an Accident & Emergency Unit . Whilst I was assured that this had been addressed by learning & guidance to call handlers, a review of categorisations, coding & actions in the setting of a patient demonstrating the symptoms as per the deceased on 28/29 October 2020 to achieve clarity/consistency is invited.
” 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 Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.
Verbatim wording from the response “During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident.” Source location 2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_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 Drug-specific overdose responses cannot be incorporated because drugs vary widely and prioritisation is based on current condition, not potential future deterioration.
Verbatim wording from the response “The issues of investigating different actions for different drug types are twofold. There is the fact that the individual drugs that can be involved in overdose cases are many and varied. Additionally, this moves away from the basis of the Trust’s Clinical Response Model, where the sickest patients are identified and attended first. This Model is based on the patient’s condition at the time and is not based on potential future changes to their conditions.” Source location 2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
Open published response
28 Jan 2022 Barbara YOUNG · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Delays in providing a timely emergency ambulance response View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barbara YOUNG · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Young fell downstairs at home, sustained multiple injuries, developed pneumonia after becoming immobile in hospital, and died on 23 July 2021. The principal concern was that an ambulance took approximately three hours to arrive despite information about her severe injuries and reduced consciousness; the report states that it could not confirm whether the delay contributed to her death, but identified an ongoing risk from delays in timely emergency response.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing a timely emergency ambulance response
Wider context from the report “I am informed that the risk of mortality in the elderly who have suffered significant trauma is high, because they are at greater risk of developing pneumonia. It is therefore essential that they receive emergency medical care as soon as possible. In this case it took 3 hours for an ambulance to arrive and whilst I have no evidence that this delay contributed to Mrs Young’s death similarly I cannot confirm it did not, and that future lives could be at risk due to the delays in providing a timely emergency response .
I acknowledge the problems faced by the ambulance service over the last 2 years, problems that have been compounded by the effects of the pandemic and delays in transferring patients into hospital emergency departments. I have also been informed that there have been plans in place to improve the responsiveness of the service however from the evidence provided at this inquest it appears that problems still exist .
” 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 Work with Health Boards to minimise hospital handover delays through on-site support and prioritisation of patients with greatest clinical need.
Verbatim wording from the response “Handover Delays” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Support out-of-hours patient discharge and transfer to release hospital beds and improve emergency-department flow.
Verbatim wording from the response “Discharge and Transfer” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Increase the pan-Wales workforce by 236 full-time-equivalent staff through recruitment and training.
Verbatim wording from the response “Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. The staff have been recruited and trained as part of our established Emergency Medical Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 22/23 to ensure staff are on duty at the time and in the place that best match patient demand. This will release an internal efficiency equivalent to 72 FTE.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Review falls Medical Priority Dispatch System codes and assign four suitable codes directly to Falls Assistants without clinical triage.
Verbatim wording from the response “The Trust continues to work with partners to further expand the model, to ensure patients are able to receive a timely response. In December the Trust undertook a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response. Following a review, four codes were identified as suitable for Falls Assistants (non-registered, in some areas St John Service) to attend without the need for Clinical Triage, thus reducing the requirement to send an Emergency Ambulance. Furthermore, improvements are actively being considered to improve utilisation of resources and support patients who are waiting for a response. A Quality Improvement Workshop has been prioritised for April, with representatives from across the organisation to identify tests of change and prioritise improvements.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Continue reviewing and updating falls and frailty dispatch guidance to optimise resource use and support correct outcomes.
Verbatim wording from the response “CSD clinicians have the ability to change the responding priority of an incident based on a secondary clinical assessment, this includes increasing the priority where the patient’s clinical acuity indicates this is appropriate. Dispatch guidelines regarding falls and frailty responders are continually reviewed and updated to ensure maximum utilisation of this valuable resource, part of the CSD role is to provide support to falls assistants following an initial assessment to ensure the correct outcome is reached.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Reroster all staff during the third quarter of 2022–23 to align staffing with patient demand and release internal efficiency.
Verbatim wording from the response “Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. The staff have been recruited and trained as part of our established Emergency Medical Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 22/23 to ensure staff are on duty at the time and in the place that best match patient demand. This will release an internal efficiency equivalent to 72 FTE.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Continue recruiting and training Advanced Paramedic Practitioners to treat suitable patients in their homes and reduce unnecessary emergency-department conveyance.
Verbatim wording from the response “Reducing Conveyance to ED Departments” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Double Clinical Contact Centre clinical staffing to reduce unnecessary ambulance dispatches and conveyance.
Verbatim wording from the response “Consult and Close” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Implement and use the enhanced Clinical Safety Plan to manage extreme pressure, communicate delays, and protect responses for immediately life-threatening conditions.
Verbatim wording from the response “Clinical Safety Plan (CSP)” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 community first responders and Fire and Rescue Services to provide designated responses for patients who have fallen.
Verbatim wording from the response “In addition to the specialist falls response, the Trust are working with volunteers (community first responders) and Fire and Rescue Services to provide a designated response to patients who have fallen to ensure periods of immobility are reduced. Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Maintain the Falls Assistant response model, including the National Falls Assistant Service and additional Trust-funded night vehicles.
Verbatim wording from the response “Additionally, in 2018, Working in partnership with St John Cymru Wales, the Trust introduced the role of the Falls Assistants (FA). The FA predominately provide a response to patients who have no injuries or where there is a concern for welfare. However, they are able to respond to patients with other medical/fragile presentations, or if there is an injury. This decision will often be supported by a clinical triage and assessment by a clinician, over the phone, prior to allocation. The aim of this new level of response was to ensure those patients often presenting with lower clinical acuity, were provided with a timely response to reduce the risk of further harm.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Recruit Patient Flow Coordinators and secure winter private ambulance clinician support to facilitate safe, timely hospital transfers.
Verbatim wording from the response “with assistance from nursing and medical staff, prioritising those patients with the greatest clinical need. As an example, a number of Patient Flow Coordinators have been recruited to support the wider system flow pressures at the Grange Hospital, Cwmbran. In addition, we secured support from Private Ambulance Service clinicians over the winter months. The purpose of the approach is to facilitate safe timely transfers for a cohort of patients from the Trust ambulances when there is no capacity within the Emergency Department (ED) or elsewhere in the hospital to facilitate timely off-load. That said, delayed transfer of care remains a significant barrier our ability to respond to calls in the community in a timely fashion with 25% of our on duty fleet capacity lost in this way in February.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 Refer elderly falls categorisation to the Clinical Priority Software Advisory Group for consideration.
Verbatim wording from the response “The appropriateness of the priority given to each category of call is reviewed and changes are considered by the Trust’s Clinical Priority Software Advisory Group (CPAS). In all cases the group will consider the impact any change would have on the volume of each priority of calls received, for example the effect of increasing the number of Red calls would have an impact on all other codes. The CPAS group also sets an “ideal” response for each type of call, in an attempt to maximise efficient use of resources by avoiding “double dispatch” on calls.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_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 System pressures, including hospital handover delays and staffing impacts, limit the Trust’s ability to provide the desired ambulance response level.
Verbatim wording from the response “I am able to provide you with absolute assurance that the negative and sometimes catastrophic impact the systems pressures are having on patients in our communities is constantly being reviewed and escalated at the highest level. I can also assure you, that the Trust has already taken many actions to try and mitigate the effects of ambulances being delayed at hospital, which then effects our ability to respond to people in the community. As I am sure you will appreciate, none of these matters sit in isolation but are interlinked. I wish to assure you that the Trust has made several changes and taken actions, over and above those I have listed here. However, I have selected the issues and actions that I hope best demonstrates that the Trust has considered every possible way in which we can react to and mitigate the impact of these pressures, which are fundamentally outside of our control.” Source location 2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Open published response
Concerns raised 3 Insufficient WAST resources to meet stroke response targets View source Lack of a specific time target for stroke care View source Inappropriate grading of stroke patients falling in the amber category 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
Andres 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
Andres Roberts suffered a large stroke and was taken to Morriston Hospital after four emergency calls, with the ambulance arriving 2 hours and 20 minutes after the incident was reported. He received thrombolysis and later suffered a large intracranial bleed before dying at the hospital. Concerns included the grading of acute stroke patients, whether a specific response-time target should be set, and whether additional ambulance resources were needed.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient WAST resources to meet stroke response targets
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific time target for stroke care
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate grading of stroke patients falling in the amber category
Wider context from the report “(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment"
(2) My concerns centre on :-
A) the appropriateness of the grading of stroke patients falling in the amber category and
B) whether a specific time target should be set and
C) whether additional resources should be made available to WAST to meet these targets
” 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 Implement the Clinical Response Model, including removal of timed targets except for immediately life-threatening conditions.
Verbatim wording from the response “Each ambulance service has a response model that supports the categorisation given to each call (irrespective of which prioritisation system is used). That response model and the decisions made will reflect the demographics of the population and the geography being served by that individual ambulance service. In 2015 the Welsh Ambulance Services NHS Trust introduced its current Clinical Response Model (the Model), which removed timed targets for all but those patients with immediately life-threatening illnesses or injuries. The Model underwent a trial period before being approved by the Welsh Government and fully implemented by the Trust.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
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 Introduce additional paramedics, emergency medical technicians and urgent care staff to increase roster relief capacity and ambulance provision.
Verbatim wording from the response “In relation to whether additional resources should be made available to the Trust to meet these targets, the Trust has undertaken a Demand and Capacity review, which has identified the need for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority of these additional staff will be introduced over the next 4 years to increase the relief capacity within the current rosters, allowing for increased ambulance provision to meet demand.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
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 Expand clinical desk staffing in the 999 control room to support timely assessment and appropriate resource allocation.
Verbatim wording from the response “• We have expanded our clinicians on the clinical desk in our 999 control room to support timely clinical assessment and to ensure we are sending the appropriate resource to the individual patient.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a Demand and Capacity review to identify additional staffing requirements across Wales.
Verbatim wording from the response “In relation to whether additional resources should be made available to the Trust to meet these targets, the Trust has undertaken a Demand and Capacity review, which has identified the need for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority of these additional staff will be introduced over the next 4 years to increase the relief capacity within the current rosters, allowing for increased ambulance provision to meet demand.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
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 No specific response-time target is considered necessary because clinically important timing runs from symptom onset to hospital arrival.
Verbatim wording from the response “Following receipt of the Regulation 28, and consideration of the facts within, I would sincerely appreciate the opportunity to discuss these with you, as the Trust does not propose, at this time, to take any action in relation to the three matters you have raised. The reasons for which I will explain below.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
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 principal issue is not stroke-call categorisation; prioritisation by clinical severity is considered appropriate.
Verbatim wording from the response “In closing, I am of the view that the principle issue for us here is not one of categorisation as it is right to have a system of priority that assigns more rapidly to clinical severity.” Source location 2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Open published response
9 Sep 2020 Alyn Rees · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Lack of an indicated expected response time for Amber 1 calls View source Failure to advise callers of the expected emergency ambulance arrival time View source Delays in transferring patients into hospital care, preventing emergency ambulance release View source Delays in emergency ambulance response 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.
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AI-generated summary
Alyn Rees · 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
Alyn Rees became acutely unwell on 3 December 2019, experienced breathing difficulties, deteriorated into cardiac arrest, and died after paramedics were unable to revive him. Concerns were raised about the approximately two-hour wait for an emergency ambulance, the lack of advice about the expected arrival time, the absence of an indicated response time for an Amber 1 call, and delays transferring patients into hospital care that prevented ambulances from being released.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an indicated expected response time for Amber 1 calls
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be .
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise callers of the expected emergency ambulance arrival time
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients into hospital care, preventing emergency ambulance release
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals . This is also of significant concern as it prevented emergency ambulances being released .
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency ambulance response
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance . At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” Open source report
Concerns raised 3 Failure to require pre-alerts for suspected sepsis in life-threatening time-critical situations View source Unavailability of intravenous antibiotic administration by ambulance paramedics when emergency department admission is delayed View source Absence of a policy or procedure for escalating concerns about patient condition and delayed admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samantha Brousas · 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
Samantha Brousas became critically ill with suspected sepsis and was taken to hospital, where she was diagnosed with septic shock secondary to pneumonia and died from a naturally occurring infection. The report identified concerns about the absence of a pre-alert to the emergency department, the inability of paramedics to administer intravenous antibiotics, and the lack of a clear process for escalating concerns about delayed admission.
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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require pre-alerts for suspected sepsis in life-threatening time-critical situations
Wider context from the report “(1) During the course of the inquest I heard evidence that the two paramedics who attended the home address of the deceased identified her as having a NEWS score of 13 with suspected sepsis. Both paramedics made a joint decision not to pre alert the emergency department at Wrexham Maelor hospital whilst being aware that there were already ambulances waiting outside the emergency department. I heard evidence that this was against the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) clinical guidelines that if sepsis is identified an alert SHOULD be made. At that time the Welsh Ambulance Service Trust (WAST) had in effect a Clinical Notice regarding the use of the ASCHICE mnemonic but not the circumstances under which it was to be used creating room for discretion to be exercised. It was accepted as part of a WAST investigation that a pre-alert should have been used. My finding on the evidence was that ‘the absence of a pre alert meant that the ED had no opportunity to prepare for Sam’s arrival and there could have then been no doubt as to the severity of her illness or her condition’ and ‘it would least have had the effect of alerting the department that a critically unwell patient was on their way and enabling them to make efforts to find or make a bed for the deceased’.
To be clear my finding was that the absence of a pre alert did not affect the outcome. I heard evidence that in December 2018 WAST issued a further clinical notice clarifying the expectations for the use of the pre alert but this fell short of a mandatory requirement for a pre alert for suspected sepsis.
My concern is that this creates a direction which is not compatible with the JRCALC guidelines and may result in a similar situation where a pre alert is not used in a life threatening time critical situation as happened with the deceased, which may present a risk to life.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of intravenous antibiotic administration by ambulance paramedics when emergency department admission is delayed
Wider context from the report “(2) I heard evidence during the course of the inquest that the first line treatment for sepsis was the administration of anti-biotics within an hour of arrival at a hospital consistent with the SEPSIS SIX and NICE guidelines. I also heard evidence that it was currently beyond the scope of the practice of WAST paramedics to administer antibiotics intravenously in an ambulance. Given the importance of the role of the Paramedic in the early diagnosis of Sepsis my concern is that when a patient is unable to be admitted into the emergency department in similar situations as the deceased, the absence of the administration of antibiotics increases the mortality risk of such patients which could be addressed by exemptions and local organisational level policies and procedures.
” 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 Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a policy or procedure for escalating concerns about patient condition and delayed admission
Wider context from the report “(3) During the course of the inquest I heard evidence that both paramedics attending the deceased had significant concerns about both the patient’s condition and the delay in admission into the ED. Despite these concerns, neither paramedic escalated these concerns either through Ambulance Control or through hospital escalation channels (which were known to Ambulance Control). My concern is that there was an absence of a policy or procedure whereby staff could escalate such concerns thereby missing an opportunity to highlight individual cases requiring immediate escalation in the absence of any clear management plan for the patient’s admission .
” 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 Design an agreed escalation process for crews when emergency department staff do not act on their clinical concerns.
Verbatim wording from the response “Patients in the Emergency Department or held in the back of the Emergency Ambulance on the forecourt are recognised in the 2016 Welsh Health Circular as the responsibility of the Health Board. As such, at all times, Trust crews should be able to escalate any clinical concerns directly to the Emergency Department via the ambulance triage nurse, nurse in charge or other senior clinician and reasonably expect action to be taken. Given the findings of the inquest, the Trust are actively designing an agreed escalation process that crews can use on the occasions that their concerns are not felt to be acted upon by staff in the Emergency Department.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement pre-alert guidance for suspected sepsis, developed with Welsh Health Board clinical directors and the Royal College of Emergency Medicine Wales.
Verbatim wording from the response “At the time that the incident occurred, the Trust did not have pre-alert guidance in place. This was rectified in December 2018. The guidance was developed in conjunction with the Clinical Directors from each Health Board Area in Wales and Royal College of Emergency Medicine Wales. [ref Clinical Notice 16/2018]” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 Conduct the PhRASe feasibility study, including paramedic screening, randomisation, blood-culture collection and intravenous antibiotic administration, and complete anonymised follow-up analysis.
Verbatim wording from the response “The PhRASe (Prehospital Recognition and Antibiotics for 999 patients with severe Sepsis) study was designed to determine if it was feasible for Trust paramedics to select and screen eligible patients, then randomise them to usual care or intervention (blood culture collection and administration of IV antibiotics). The main purpose of the study was to gather evidence, to inform the feasibility of a definitive study that could examine the effectiveness of prehospital antibiotics. This study is in the final stages of data analysis of anonymised follow-up via the SAIL databank.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 Deliver mandatory training and a national education session to help emergency medical services staff recognise sepsis red flags and use pre-alerts.
Verbatim wording from the response “The 2017 Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Supplementary Guidelines stated a pre-alert should be given for suspected sepsis, a message that was further reinforced on the Trust’s pre-alert guidance. In addition, the updated 2017 sepsis guidelines were covered during the 2018/19 mandatory training” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 Health Boards are responsible for patients in Emergency Departments or ambulances held on hospital forecourts, including addressing escalated clinical concerns.
Verbatim wording from the response “Patients in the Emergency Department or held in the back of the Emergency Ambulance on the forecourt are recognised in the 2016 Welsh Health Circular as the responsibility of the Health Board. As such, at all times, Trust crews should be able to escalate any clinical concerns directly to the Emergency Department via the ambulance triage nurse, nurse in charge or other senior clinician and reasonably expect action to be taken. Given the findings of the inquest, the Trust are actively designing an agreed escalation process that crews can use on the occasions that their concerns are not felt to be acted upon by staff in the Emergency Department.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 Trust will not provide routine pre-hospital antibiotics because evidence, training, equipment, costs and antimicrobial-resistance concerns constrain implementation.
Verbatim wording from the response “Therefore, the current evidence base is not strong enough to demonstrate the benefits of out-of-hospital administration of antibiotics in sepsis by all paramedics, including time taken to train, the costs involved to purchase the additional medications and equipment, and maintain competency in the use of the drugs. In addition, controlled use of antibiotics is considered best practice to prevent antimicrobial resistance, which is on the increase.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 An exhaustive mandatory pre-alert policy is not feasible because clinical circumstances are too complex for an all-encompassing list.
Verbatim wording from the response “It would not be feasible to create a policy which dictated all circumstances in which a pre-alert is needed as, by logical extension, doing so would also create a (longer) list of conditions that do not require pre-alert.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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 Health Board Emergency Department staff are responsible for initiating antibiotics for patients delayed in ambulances because they prescribe and select appropriate treatment.
Verbatim wording from the response “The Trust advocates that any administration of antibiotics for patients with red flag sepsis should be initiated within the Emergency Department and not in the back of an Emergency Ambulance. For patients held in the back of ambulances due to excessive” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations