22 Oct 2019 Mr Paul Mclean · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure to ask callers how long the patient has been fitting View source Lack of a pathway for updating prison emergency-call operators about WAST call-prioritisation changes View source Failure to consistently categorise non-maintenance of airways as a continuous red code View source Lack of a clear clinical dialogue pathway for appropriate emergency-call categorisation View source See 1 more concern
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AI-generated summary
Mr Paul Mclean · 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
Mr Paul Mclean died on 9 October 2018 after prolonged status epilepticus, following an emergency call to the Welsh Ambulance Service on 22 July 2018. The initial call was downgraded from code red to amber, resulting in an approximately 80-minute response instead of the anticipated 15–20 minutes; the jury found that the extended response contributed to prolonged status epilepticus and his subsequent death. The principal concerns related to seizure-call question scripting and categorisation, recognition of airway problems, and communication pathways between the ambulance service, prison healthcare operators, and hospital clinicians.
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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 to ask callers how long the patient has been fitting
Wider context from the report “1. The adequacy/accuracy of the scripting of questions for seizure/fitting calls. In particular, and in relation to code 12D02 calls (post 19.6.19) the requirement for a healthcare professional to call back after 20 minutes of continuous fitting to trigger a call upgrade from Amber 1 to Red.
In an email from ████████ of 17.10.19 @ 07.11 and read to the court, it was confirmed that the question is not currently asked of the caller to WAST, how long has the patient been fitting?
This would appear to be a crucial piece of information in order to ascertain as accurately as possible, the known timing of the onset of the fit, for the purposes of determining when the 20minutes has elapsed. E.g. if it is known that the patient has already been fitting for 10 minutes, then the advice to call back should be in 10 minutes hence. If the fit has just commenced, then obviously, that advice can be for a 20 minute call back.
” 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 pathway for updating prison emergency-call operators about WAST call-prioritisation changes
Wider context from the report “3. Whether a pathway exists, or should be created for updating G4S – the operators of Parcison with changes implemented by the WAST affecting call prioritisation . This is likely to have the benefit of ensuring that healthcare professionals at the prison are fully aware of what is expected of them in an emergency call to WAST and what response can be expected from WAST at the time an emergency call is placed.
” 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 consistently categorise non-maintenance of airways as a continuous red code
Wider context from the report “2. The wider issue of whether a response from a healthcare professional (to a question(s) posed by a call handler) that the patient is not maintaining his/her airways should in itself trigger/categorise a continuous red code . The evidence of ████████ at the Inquest, was that such a scenario was of the highest clinical priority, as the patient had a high risk of cardiac arrest in such circumstances. There appeared some tension in the evidence surrounding the 12D01/02/03 categorisation as to which code would be triggered on the volunteering, or otherwise of this indication from the caller.
” 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 clear clinical dialogue pathway for appropriate emergency-call categorisation
Wider context from the report “4. Whether there is, or should exist, a clear pathway for dialogue between the Princess of Wales Hospital Emergency Department clinicians and WAST in relation to best practice for call categorisation . In particular, whether there should be regular input from the emergency department consultants at the Princess of Wales Hospital into the CPAS group for the purposes of assisting in relation to the appropriate categorisation of calls .
” 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 Implement escalation arrangements for healthcare professional callers requiring urgent clinical discussion, including prioritised clinical review of waiting calls.
Verbatim wording from the response “The actions to be taken when the urgency of the response after triage does not match the expectations of the booking HCP due to the presenting condition include:” Source location 2019-0347-Response-by-Welsh-Ambulance-Services-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 Assess whether to create bespoke emergency-call pathways for Parc Prison and decide against introducing local variation.
Verbatim wording from the response “3. Whether a pathway exists, or should be created for updating G4S – the operators of Parc Prison with changes implemented by the WAST affecting call prioritisation. This is likely to have the benefit of ensuring that healthcare professionals at the prison are fully aware of what is expected of them in an emergency call to WAST and what response can be expected from WAST at the time an emergency call is placed.” Source location 2019-0347-Response-by-Welsh-Ambulance-Services-NHS-Trust
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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 A bespoke Parc Prison pathway or local call-handling variation is not considered appropriate because it could adversely affect patients across Wales.
Verbatim wording from the response “As an All Wales Ambulance Trust we provide an all Wales service. The Trust operates three regional CCC’s who work virtually across Wales, not servicing individual Health Boards or boundaries, with calls being answered by the availability of call handlers, rather than by geographical location of the patient. Therefore, the handling of emergency calls received, is pan Wales, without regional and or local variations. This principle is also true across all of the HM Prisons across Wales.” Source location 2019-0347-Response-by-Welsh-Ambulance-Services-NHS-Trust
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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 existing pan-Wales CPAS governance framework and international MPDS system are considered sufficient for best-practice call categorisation without a separate hospital pathway.
Verbatim wording from the response “4. Whether there is, or should exist, a clear pathway for dialogue between the Princess of Wales Hospital Emergency Department clinicians and WAST in relation to best practice for call categorisation. In particular, whether there should be regular input from the emergency department consultants at the Princess of Wales Hospital into the CPAS group for the purposes of assisting in relation to the appropriate categorisation of calls.” Source location 2019-0347-Response-by-Welsh-Ambulance-Services-NHS-Trust
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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 Existing MPDS triage, clinical support and escalation arrangements are considered sufficient to prioritise healthcare professional calls appropriately.
Verbatim wording from the response “To overcome this, the Trust now use the questions through the Medical Priority Dispatch System (MPDS), to ensure that all patients across Wales are treated with parity, including HCP requests. HCP calls are consequently prioritised as Red where it is clinically appropriate.” Source location 2019-0347-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
16 Sep 2019 Ffion Louise Jones · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of a dedicated means for urgent clinical discussion between external healthcare professionals and ambulance service staff View source Failure of improvement planning to address specific shortcomings in service provision View source Risk of recurrence of the circumstances leading to the death 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
Ffion Louise 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
Ffion Jones died following an Addisonian crisis and cardiac arrest while waiting almost an hour for an ambulance at her GP’s surgery. Her urgent ambulance call was not escalated to the clinical support desk, and the report identified an ongoing lack of a dedicated means for external healthcare professionals to urgently discuss a patient’s clinical need with ambulance service staff. The report stated that there was a real risk of recurrence.
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× 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 dedicated means for urgent clinical discussion between external healthcare professionals and ambulance service staff
Wider context from the report “(2) There remains no dedicated means for an external health care professional to have urgent access to a discussion with a clinical member of ambulance service staff to ensure that their assessment of their patient’s clinical need is fully, properly and quickly conveyed to the ambulance service, and thus that there is a properly informed assessment of the urgency of the 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 of improvement planning to address specific shortcomings in service provision
Wider context from the report “(1) The Improvement plan provided at the Inquest did not include any consideration of the specific shortcomings in service provision leading to Ffion’s death and the witness speaking to it was unable to address these 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 Risk of recurrence of the circumstances leading to the death
Wider context from the report “(3) There is a real risk of the recurrence of the circumstances leading to Ffion’s death
” Open source report
15 May 2019 Marion Hilda Prance · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure of paramedics to recognise that the extent of a head injury after a fall may not be immediately obvious and to apply extra caution View source Inadequate training of paramedics about bleeding dangers in patients prescribed newer anticoagulant drugs after a fall View source Insufficient paramedic awareness of fast-acting anticoagulant drugs and the implications of administering them View source Failure of paramedics to recognise the dangers of administering Rivaroxaban View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Marion Hilda Prance · 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
Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.
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× 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 paramedics to recognise that the extent of a head injury after a fall may not be immediately obvious and to apply extra caution
Wider context from the report “(4) The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be immediately obvious, and extra caution is required .
” 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 training of paramedics about bleeding dangers in patients prescribed newer anticoagulant drugs after a fall
Wider context from the report “(2) The training of paramedics in relation to the dangers of bleeds in patients who have fallen and are prescribed Rivaroxaban and other similar new style anti-coagulant drugs ;
” 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 paramedic awareness of fast-acting anticoagulant drugs and the implications of administering them
Wider context from the report “(3) The awareness of fast-acting anti-coagulant drugs and the implications of administering them ; and
” 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 paramedics to recognise the dangers of administering Rivaroxaban
Wider context from the report “(1) A paramedic with 40 years of experience was unaware of the dangers of administering Rivaroxaban, a blood-thinning medication to an elderly lady who had suffered a fall and banged her head;
” 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 Publish Clinical Notice 18 to clinicians, covering Novel Oral Anticoagulants including Rivaroxaban and providing advice on their use.
Verbatim wording from the response “Whilst the Trust acknowledges that during the Inquest you heard verbal evidence from the paramedic who attended Mrs Prance, I would like to take the opportunity to confirm with you that during 2014 a Clinical Notice number 18 entitled, Novel Oral Anti-coagulant, was published to all clinicians. In that document anti-coagulant therapies including Rivaroxaban were referred to and advice was supplied to staff regarding their use. I attach for your reference a copy of that Clinical Notice.” Source location 2019-0154-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
Concerns raised 2 Delays in emergency response for patients with chest pains and related conditions View source Failure to categorise conscious, breathing patients with chest pains and related conditions as Category Red 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
Michael Jonathan Davies · 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
Michael Jonathan Davies, aged 52, became unresponsive after contacting emergency services about pains down his arms and back and died at home before the ambulance arrived. The inquest recorded that he died from an acute myocardial infarction and that delayed medical treatment may have contributed to his death. The report raised concerns that chest pains and related conditions were categorised as Amber 1 rather than Red, resulting in a response time of up to four hours and potentially putting patients’ lives at risk.
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× 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 response for patients with chest pains and related conditions
Wider context from the report “1. During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed in an Amber 1 categorisation whenever the patient is conscious and breathing. The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response.
2. The effect of removing chest pains and related conditions from Category Red is the response time, previously 8 minutes, is now up to 4 hours and often patients are advised to make their own way to hospital .
3. This puts patients’ lives at risk and in this inquest may have contributed to the death of Mr Davies.
” 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 categorise conscious, breathing patients with chest pains and related conditions as Category Red
Wider context from the report “1. During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed in an Amber 1 categorisation whenever the patient is conscious and breathing . The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response .
2. The effect of removing chest pains and related conditions from Category Red is the response time, previously 8 minutes, is now up to 4 hours and often patients are advised to make their own way to hospital.
3. This puts patients’ lives at risk and in this inquest may have contributed to the death of Mr Davies.
” 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 The response model appropriately assigns red priority only to chest-pain calls involving unconsciousness and absent breathing.
Verbatim wording from the response “As you explored during the inquest, 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. I notice that you have relied on evidence informing your view and subsequently raising the noted concerns that England (or parts thereof) have some chest pains as a red category of call, requiring an 8 minute response. I would respectfully draw to your attention to the fact that England operates a national system of response prioritisation (following the introduction of the Ambulance Response Program (ARP).” Source location 2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
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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 Amber 1 calls do not have planned four-hour delays, and self-transport advice is given only when clinically appropriate and safe.
Verbatim wording from the response “With regard to point 2 of the Regulation 28 Report, I would like to take the opportunity to explain that Amber 1 calls do not attract a planned response of up to four hours within the clinical response model, nor is it correct to say that patients are often advised to make their own way to hospital. It would be right to say however that around 10% of all patients who dial 999 are offered advice by a senior clinician over the telephone which may include self-care advice or instructions to make their own way to a healthcare facility. This is only the case where it is clinically appropriate and safe to do so and supports the provision of sufficient emergency ambulance capacity being available to respond to those patients who do genuinely require such.” Source location 2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
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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 Immediate vehicle allocation is not always possible when demand exceeds available ambulance supply.
Verbatim wording from the response “Whilst the Trust in its letter to ████████ and in the oral evidence provided at the inquest, acknowledges that there was a delay in an ambulance being allocated to Mr Michael Davies on 7 February 2018, this was an unavoidable delay. This is because at 11.25 hours when the call was received, and allocated the Amber 1 categorisation, there were no vehicles available to the Trust to send to Mr Michael Davies. This resulted in the open microphone call being made to all ambulances in the vicinity at 11.31 hours.” Source location 2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Open published response
Concerns raised 1 Delays in handover of patients at emergency departments 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
Madeline Constance Staples · 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
Madeline Constance Staples, an 86-year-old woman, suffered an unwitnessed fall at her care home on 6 April 2018, sustaining fractures to both legs. Delays in obtaining ambulance assistance and transporting her to hospital meant she remained in pain for several hours. The report raised concerns about repeated unacceptable delays linked to emergency department handovers and unavailable ambulance resources, placing patients’ lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in handover of patients at emergency departments
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”.
In the intervening period from then until the present either I or my Assistant Coroners have issued at least a further twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAS T (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail .
As has been stated previously in my other reports, I recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable.
” Open source report
21 Dec 2018 Diane Greenslade · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in medical intervention View source Failure to carry out a clinical assessment during initial call handling View source Failure to escalate calls appropriately after unsuccessful contact View source Failure to make contact with callers or their families View source Unavailability of nearby rapid response vehicles for calls outside red and amber 1 categories View source Excessive delays at hospitals View source See 3 more concerns
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
Diane Greenslade · 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
Diane Greenslade was found moaning on her bedroom floor with a chest of drawers on top of her after ambulance responses were delayed. She suffered a cardiac arrest and died, with the inquest concluding that she died from natural causes following a fifteen-and-a-half-hour delay in ambulance intervention. The substantive concerns included the initial call categorisation without clinical assessment, failure to consider escalation or a police welfare check, high ambulance demand and hospital delays, and a nearby rapid response vehicle being unavailable because it was reserved for higher-priority calls.
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× 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 medical intervention
Wider context from the report “(5) The delay in medical intervention must have played a significant role in Mrs Greenslade’s 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 carry out a clinical assessment during initial call handling
Wider context from the report “(1) The initial call was categorised Green 3 without any contact being made with Mrs Greenslade or her family and without any clinical assessment .
” 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 escalate calls appropriately after unsuccessful contact
Wider context from the report “(2) After failing to make contact, no consideration was given to either upgrading the call category or to contacting the Police to ask them to carry out a welfare check .
” 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 contact with callers or their families
Wider context from the report “(1) The initial call was categorised Green 3 without any contact being made with Mrs Greenslade or her family and without any clinical assessment.
” 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 nearby rapid response vehicles for calls outside red and amber 1 categories
Wider context from the report “(4) A rapid response vehicle had been based only eight minutes away from Mrs Greenslade’s home since at least 6.30 and had not responded to any calls as it was ring fenced for red and amber 1 calls .
” 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 Excessive delays at hospitals
Wider context from the report “(3) Demand for ambulances was high compounded by excessive delays at hospitals .
” 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 Align staffing availability with local and time-of-day demand.
Verbatim wording from the response “• Aligning production against demand both locally and time of day. This means ensuring we have the right levels of staff availability to meet the demand with which we are faced” Source location 2018-0401-Response-by-Welsh-Ambulance-Services
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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 Commence an all-Wales demand and capacity review to determine required operational capacity and future service demand.
Verbatim wording from the response “3. Demand for ambulances was high compounded by excessive delays at hospitals.
Unfortunately, this was the case and often has a material impact on our ability to respond in a timely and reasonable way to calls that are not immediately life threatening. As set out in the accompanying action plan, we are shortly to commence an all Wales demand and capacity review to establish exactly what operational capacity is required to ensure we respond in the majority of cases within set waiting time and quality standards. This work will also assess current demand for services and what we can expect to see in the next five years.” Source location 2018-0401-Response-by-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 Reduce hospital handover duration to release staff for further responses.
Verbatim wording from the response “• Reducing the duration of handover to clear i.e. the time it takes for our staff to become available following the handover of a patient to another care provider, generally hospital staff” Source location 2018-0401-Response-by-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 a Memorandum of Understanding with police regarding the issue.
Verbatim wording from the response “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check.
Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.” Source location 2018-0401-Response-by-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 policies and procedures for establishing contact with patients or callers at scene.
Verbatim wording from the response “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check.
Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.” Source location 2018-0401-Response-by-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 Train relevant Clinical Contact Centre staff.
Verbatim wording from the response “• Training of relevant Clinical Contact Centre staff” Source location 2018-0401-Response-by-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 clinicians within Clinical Contact Centres.
Verbatim wording from the response “• Recruitment of clinicians within the Clinical Contact Centre” Source location 2018-0401-Response-by-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 Reduce conveyance where safe and provide appropriate care at home using advanced practitioners.
Verbatim wording from the response “• Reducing conveyance where safe and appropriate, and providing care in the patient’s home utilising advanced practitioners” Source location 2018-0401-Response-by-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 Adopt a more dynamic approach to managing rapid response vehicles within each health board area.
Verbatim wording from the response “The Trust uses the Resource Escalation Action Plan or REAP to provide services during periods of increased demand or other NHS wide system pressures. The REAP is a UK agreed document used by all 13 NHS ambulance services, with some key actions and locally agreed operational tactics.” Source location 2018-0401-Response-by-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 Police attendance for ambulance 999 welfare checks is considered inappropriate because police officers lack training for clinical assessment.
Verbatim wording from the response “2. After failing to make contact, no consideration was given to either upgrading the call category or to contacting Police to ask them to carry out a welfare check.
Whilst we have set out in this correspondence that we are reviewing our policies and procedures around establishing contact with a patient or caller at scene, we are of the view that it would not be appropriate to request police attendance to undertake welfare checks for 999 calls to the ambulance service, as police officers are not suitably trained to make a clinical assessment. However, we are working collaboratively with our Police Force colleagues to develop a Memorandum of Understanding regarding this issue.” Source location 2018-0401-Response-by-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 Rapid response vehicles are reserved for immediately life-threatening calls, so lower-priority calls may wait longer.
Verbatim wording from the response “One of the aims of REAP is to ensure that we have a resource available for a cardiac arrest or other high priority RED calls. In order to ensure this, the Trust reserves rapid response units for RED calls in REAP level 3 and 4. Whilst this means that some lower priority calls may wait longer for a response, it does ensure that we are always able to respond immediately to RED calls. I would like to assure you that we have reviewed” Source location 2018-0401-Response-by-Welsh-Ambulance-Services
Open published response
2 Oct 2018 Andrew Collins · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of ambulance resources for timely attendance to critically unwell and deteriorating patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Collins · 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
Andrew Collins became acutely unwell at home on 6 June 2018 with a severe headache, was found to have a subdural haematoma, underwent emergency neurosurgery, and died on 16 June 2018. The report raised concern about a delay of approximately three hours in sending an ambulance despite his rapidly deteriorating condition, attributed to a lack of available resources.
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 ambulance resources for timely attendance to critically unwell and deteriorating patients
Wider context from the report “(1) There was a delay of some 3 hours in sending an ambulance to Mr Collins when it was clear that his clinical picture was rapidly deteriorating.
The first 999 call was received at 16:10 on the 6th June and correctly categorised but no vehicle was available to be dispatched to assist him . A further 999 call was made by his partner at 18:09 and again at 18:55 at which point he was described as “just about breathing and just about conscious”. An ambulance became available and was on scene at 19:10. He was conveyed to the University Hospital of Wales at 20:08 and handed over to hospital staff at 20:26.
Whilst the evidence suggested the calls to the ambulance service were correctly categorised as having urgent clinical priority a clear lack of resources meant that there was a significant delay in attending to a critically unwell and deteriorating patient which, in my opinion must create a risk that further deaths may occur.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the scope of practice for Community First Responders.
Verbatim wording from the response “The accompanying action plan will provide you with the detail of this work, in addition to other quality improvement initiatives designed to safely release resources to respond to patients in greatest need. This includes the introduction of a Falls Framework and increasing scope of practice for our Community First Responders.” Source location 2018-0336-Response-by-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 Align resource production with demand by location and time of day.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-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 Reduce handover-to-clear duration.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-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 Strengthen out-of-hospital alternative pathways to improve care efficiency and resource use.
Verbatim wording from the response “I would like to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board, continue to work in collaboration to drive the improvements forward. We continue to strengthen the out of hospital alternative pathways to improve efficiency and effectiveness of care for our patients and make best use of our resources.” Source location 2018-0336-Response-by-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 Reduce conveyance where safe and appropriate by providing care at home through advanced practitioners.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-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 Ensure planned resources are sufficient to meet overall demand.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-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 robust review of the Explorer Project.
Verbatim wording from the response “In addition to the actions contained within the attached plan, the Trust has undertaken and completed a robust review of the “Explorer Project”. The aim of this was the introduction of “ring fencing” to stabilise resource capacity in the Cwm Taf area and to prevent the migration of emergency resources into busier adjacent Health Board areas.” Source location 2018-0336-Response-by-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 Introduce safe alternatives to responding at scene where appropriate.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-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 Reduce sickness absence.
Verbatim wording from the response “The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:” Source location 2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
Concerns raised 4 Failure to provide timely admission to the emergency department View source Failure of patient flow processes View source Unavailability of required resources View source Delays in ambulance response or transfer 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
Gladys May Williams · 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
Gladys May Williams fell at her care home on 6 March 2018, was discharged from hospital, deteriorated, and experienced delays in ambulance response and handover on 7 March. The report raises continuing concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that patients’ lives may be at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” 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 patient flow processes
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” 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 required resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” 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 response or transfer
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” Open source report
7 Aug 2018 Mr. Steven John Welch · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of employed interventional radiologists to provide tertiary support View source Lack of software enabling electronic transfer of radiology for external review and consultation View source Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores View source Delays in transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment 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
Mr. Steven John Welch · 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
Mr. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.
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 employed interventional radiologists to provide tertiary support
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” 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 software enabling electronic transfer of radiology for external review and consultation
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation .
” 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 rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays ;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” 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 to hospitals or specialist centres providing neurosurgical diagnosis and treatment
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital ;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” Open source report
30 Jul 2018 Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to request police assistance for welfare checks when ambulance resources are constrained View source Delays in making and chasing-up welfare calls View source Failure to re-categorise incidents when welfare-call information indicates increased risk View source Failure of demand analysis to accurately estimate required ambulance capacity View source Unrealistic target turnaround time for ambulances at A&E View source Failure of call handlers to establish relevant overdose risk information View source See 3 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
Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.
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 request police assistance for welfare checks when ambulance resources are constrained
Wider context from the report “(4) The police could have been asked to perform a welfare check.
Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival.
” 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 making and chasing-up welfare calls
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back . It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” 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 re-categorise incidents when welfare-call information indicates increased risk
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident .
” 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 demand analysis to accurately estimate required ambulance capacity
Wider context from the report “(1) ‘Demand analysis’ seriously underestimated the number of ambulances required in Cardiff and the Vale that night.
Evidence showed that only 7 ambulances were available up until 2am, then 5 available up until 3am . Also 7 hours of ambulance time was lost during the period 02:26 – 06:30 due to delays at A&E.
” 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 Unrealistic target turnaround time for ambulances at A&E
Wider context from the report “(3) The target turnaround time for ambulances at A&E is wildly unrealistic.
Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes . Such delay must have a knock-on effect upon the ‘demand analysis’.
” 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 handlers to establish relevant overdose risk information
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” Open source report
Concerns raised 4 Delays in ambulance response View source Lack of availability of resources View source Failures in patient flow View source Failures in admission to the emergency department 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
Margaret Megan Evans · 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
Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.
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
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 availability of resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 Failures in patient flow
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 Failures in admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report
Concerns raised 4 Failure to maintain safe patient flow View source Unavailability of required healthcare resources View source Delays in ambulance response or conveyance View source Failure to ensure timely admission to the emergency department 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
Ester Jane Wood · 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
Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain safe patient flow
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 required healthcare resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 response or conveyance
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 timely admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” Open source report
Concerns raised 4 Failure to ensure availability of resources View source Failure of patient flow processes View source Continuing problems with admission to the emergency department View source Continuing ambulance delays 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
Daphne Edith Williams · 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
Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her death.
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 ensure availability of resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” 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 patient flow processes
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” 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 Continuing problems with admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” 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 Continuing ambulance delays
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” Open source report
Concerns raised 4 Delays in emergency department patient handover View source Failure to maintain adequate emergency department staffing View source Insufficient hospital bed capacity for admissions View source Failure of hospital patient flow and delayed transfer of care processes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lilly Baxandall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency department patient handover
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls" .
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays /bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate emergency department staffing
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients" .
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital bed capacity for admissions
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions ”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care .
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment ”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report
27 Apr 2017 Anton Kusz · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Delays in hospital handover causing unavailability of ambulances View source Insufficient clinician capacity for timely secondary triage of 999 calls View source Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care View source Delays in providing ambulance responses to urgent 999 calls 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
Anton Kusz · 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
Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.
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 hospital handover causing unavailability of ambulances
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 clinician capacity for timely secondary triage of 999 calls
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 providing ambulance responses to urgent 999 calls
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent . It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” Open source report
Concerns raised 4 Patient flow failing to enable admission of patients requiring treatment View source Delays in admission to hospital View source Delays in handover of patients at an Emergency Department View source Unavailability of ambulance resources for allocation to other calls 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
Rebecca Anne Evans · 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
Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and 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 Patient flow failing to enable admission of patients requiring treatment
Wider context from the report “3. It is of grave concern to me that my statutory duty requires me to report these concerns by way of regulation 28 reports on a very regular basis and that despite previous such reports there continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment .
” 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 admission to hospital
Wider context from the report “1. That there were significant delays in the admission of Ms Evans to Hospital and that medical treatment was consequently not commenced in a timely manner.
” 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 handover of patients at an Emergency Department
Wider context from the report “2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” 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 ambulance resources for allocation to other calls
Wider context from the report “2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls . Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” Open source report
1 Mar 2017 Ceriann Richards · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Delays in ambulance-to-hospital handover 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
Ceriann Richards · 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
Ceriann Richards was found acutely unwell and suffering seizures at home on 14 August 2016. An ambulance took approximately three hours to convey her to hospital, where she died later that morning. A post-mortem found very high, toxic levels of Venlafaxine, while the principal concern was delay in ambulance despatch linked to hospital handover delays.
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-to-hospital handover
Wider context from the report “(1) The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals within the Aneurin Bevan University Health Board Areas which on that day for the Royal Gwent Hospital were of an average of 107 minutes up to a maximum of 279 minutes and for the Neville Hall Hospital with an average delay of 43 minutes and the longest delay of 93 minutes. The evidence revealed that the agreed “handover time” is 15 minutes. The evidence further revealed that since guidance was issued in the spring of 2016 in relation to the handover from ambulance crews to hospital staff the position has worsened and in the order of 140 to 200 hours are lost each day equating to 10 to 20 vehicles being off road for the whole day across the Welsh Ambulance Trusts Area .
” Open source report
Concerns raised 4 Lack of a finalised care pathway for patients presenting with an infected prosthesis View source Failure of patient flow within the Maelor Hospital causing delays in the Emergency Department View source Delays in transferring patients from ambulances and releasing ambulance resources for other calls View source Delays in administering antibiotics after knee aspiration 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
Pamela June Conway · 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
Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical 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 Lack of a finalised care pathway for patients presenting with an infected prosthesis
Wider context from the report “1. Evidence at the inquest indicated that discussions were taking place between different departments within BCUHB with a view to agreeing a protocol to establish an appropriate care pathway for patients presenting to the hospital with an infected prosthesis, however nothing had been finalised regarding the same .
” 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 patient flow within the Maelor Hospital causing delays in the Emergency Department
Wider context from the report “2. Evidence at the inquest indicated that the problem of “patient flow” within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests.
” 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 from ambulances and releasing ambulance resources for other calls
Wider context from the report “1. That notwithstanding changes which have been made by both BCUHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.
” 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 administering antibiotics after knee aspiration
Wider context from the report “2. Furthermore evidence indicated that although it was always intended that antibiotics would be administered once the patient's knee had been aspirated, there was a delay of almost two hours between this procedure and the administration of antibiotics (a delay which was explained by being due to “normal hospital procedures” ).
” Open source report
20 Apr 2016 Ronald Hamer · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure to provide timely ambulance responses to Amber 2 calls View source Failure to make timely follow-up calls to update, advise and reassess emergency callers View source Lack of clear planning and direction for maintaining and delivering ambulance services View source Failure to maintain ambulance service delivery during significant call volumes 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
Ronald Hamer · 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
Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.
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 provide timely ambulance responses to Amber 2 calls
Wider context from the report “1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes . It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again .
” 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 timely follow-up calls to update, advise and reassess emergency callers
Wider context from the report “2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call . A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made .
” 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 clear planning and direction for maintaining and delivering ambulance services
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” 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 ambulance service delivery during significant call volumes
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled . The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” 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 Develop an action plan addressing the Regulation 28 improvement requirements.
Verbatim wording from the response “I am writing in response to your letter dated 20 April 2016 and the Regulation 28 Report to Prevent Future Deaths issued by your office, following the inquest of Mr Ronald Hamer (Deceased). I would like to provide you with assurance that we are making progress with the actions being led by named individual staff and partners in order to take forward the key actions for improvement. Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.” Source location 2016-0149-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
15 Jan 2016 Jasmine Ruby Lapsley · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 5 Lack of an effective rota system for consistent Community First Responder cover View source Failure to provide increased resources during the July and August population increase View source Unavailability of reliable air support in North West Wales during overnight hours View source Insufficient planning for recruitment and retention of local Community First Responders View source Unreliable communication for contacting Community First Responders in remote and/or rural areas View source See 2 more concerns
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
Jasmine Ruby Lapsley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 19 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective rota system for consistent Community First Responder cover
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide increased resources during the July and August population increase
Wider context from the report “(4) The population of many rural and remote areas of North West Wales increases significantly during the months of July and August. WAST currently do not provide increased resources during these two months to cope with this increase in population . WAST should review their planning for effective allocation of resources to ensure the safety of this population during the months of July and August.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of reliable air support in North West Wales during overnight hours
Wider context from the report “(1) There is no reliable WAST Air Support in North West Wales during the hours of 20.00 hours and 07.00 hours , those being the hours not covered by Wales Air Ambulance or the recently introduced Emergency Medical Retrieval Teams. WAST should review this gap in air support which is an essential asset in accessing, treating and retrieving critically ill or injured patients, particularly in remote and/or rural areas .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning for recruitment and retention of local Community First Responders
Wider context from the report “(3) Given the difficulties in ambulances arriving at many rural and/or remote areas in North West Wales it is essential that there are sufficient local Community First Responders to arrive promptly at the casualty and provide essential treatment preserving life until an ambulance arrives . WAST should review the planning for the recruitment and retention of Community First Responders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Ambulance Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable communication for contacting Community First Responders in remote and/or rural areas
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent . WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” Open source report
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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 Raise North Wales air-support coverage requirements with the Chief Ambulance Services Commissioner and relevant committee.
Verbatim wording from the response “1.3 Increase funding for Welsh Air Ambulance to cover the night service. The Welsh Air Ambulance is by an additional helicopter (135 model night HEMS approved) in July 2016 for night time cover – will be on trial between 12 noon – 10pm. The Welsh Air Ambulance is purchasing x3 air ambulances with night capability between January – March 2017. The expansion of the North Wales Air Ambulance expansion plan is March 2017 contingent on funding for the paramedic workforce. Chief Executive of WAST have also raised the issue of cover with the Chief Ambulance Services Commissioner and the Emergency Ambulance Services Committee.” Source location 2016-0022-Response-by-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 Explore potential options for reliable overnight air support with the Welsh Air Ambulance.
Verbatim wording from the response “Action and Progress
1.1 Chief Executive for WAST and the Chief Executive for Welsh Air Ambulance have an initial meeting to explore the potential options. The meeting took place on 15th February 2016.
1.2 Actions following the meeting. Formal communications will be made by the CEO of Welsh Air Ambulance to the Chief Commissioner.” Source location 2016-0022-Response-by-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 Seek increased funding for Welsh Air Ambulance night cover.
Verbatim wording from the response “1.3 Increase funding for Welsh Air Ambulance to cover the night service. The Welsh Air Ambulance is by an additional helicopter (135 model night HEMS approved) in July 2016 for night time cover – will be on trial between 12 noon – 10pm. The Welsh Air Ambulance is purchasing x3 air ambulances with night capability between January – March 2017. The expansion of the North Wales Air Ambulance expansion plan is March 2017 contingent on funding for the paramedic workforce. Chief Executive of WAST have also raised the issue of cover with the Chief Ambulance Services Commissioner and the Emergency Ambulance Services Committee.” Source location 2016-0022-Response-by-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 Initiate a work plan for paramedic staffing of the Caernarfon helicopter.
Verbatim wording from the response “1.6 Initiate a work plan regarding paramedic staffing of the helicopter in Caernarfon following the meeting with EMRTS.” Source location 2016-0022-Response-by-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 Map capacity and demand during peak holiday periods and implement recommendations.
Verbatim wording from the response “4.2 Mapping of capacity and demand, particularly over peak holiday season.
Lead: Head of Operations BCU
Evidence: Review and recommendations in place
Completion: April 2016” Source location 2016-0022-Response-by-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 Coordinate with Community First Responders on available resources and volunteer-service arrangements.
Verbatim wording from the response “2.4 Current dialogue with CFRs around how best to coordinate use of available resources / identifying list, recognising that this is a volunteer service.” Source location 2016-0022-Response-by-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 Strengthen leadership arrangements for Community First Responder recruitment.
Verbatim wording from the response “2.1 WAST to review and strengthen the leadership arrangements for CFR recruitment.” Source location 2016-0022-Response-by-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 Discuss EMRTS business-case outcomes and additional resource requirements with the executive team.
Verbatim wording from the response “1.5 Emergency Medical Retrieval Service (EMRTS) is currently working on multiple business cases in relation to extending their service from 12 hours over a 12 hour period 7 days a week and extending the existing hours of work to 24 hours a day 7 days per week. This business case is expected to be with Welsh Government by the end of 2016.” Source location 2016-0022-Response-by-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 Pilot and roll out hand-held devices to improve communication with Community First Responders.
Verbatim wording from the response “2.2 Pilot hand-held devices to improve WAST's ability to communicate with CFRs.” Source location 2016-0022-Response-by-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 Run a Community First Responder recruitment campaign and provide adequate training.
Verbatim wording from the response “3.2 CFR recruitment campaign and ensure adequate training by the end of spring in readiness for the summer months.
Lead: Director of Operations; Assistant Director Operations
Evidence: Evidence of a clear plan and additional volunteers
Completion: June 2016” Source location 2016-0022-Response-by-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 Expansion of North Wales Air Ambulance coverage is contingent on funding for the paramedic workforce.
Verbatim wording from the response “1.3 Increase funding for Welsh Air Ambulance to cover the night service. The Welsh Air Ambulance is by an additional helicopter (135 model night HEMS approved) in July 2016 for night time cover – will be on trial between 12 noon – 10pm. The Welsh Air Ambulance is purchasing x3 air ambulances with night capability between January – March 2017. The expansion of the North Wales Air Ambulance expansion plan is March 2017 contingent on funding for the paramedic workforce. Chief Executive of WAST have also raised the issue of cover with the Chief Ambulance Services Commissioner and the Emergency Ambulance Services Committee.” Source location 2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
Open published response
Concerns raised 1 Delays in ambulance attendance 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
Christopher George Connor · 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
Christopher George Connor had been socialising at a public house before leaving in the early hours and being found collapsed and unresponsive on a pavement near his home. An ambulance took over 1 hour and 15 minutes to arrive, and the principal concern was the delay in ambulance attendance.
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 “(1) The delay in the attendance of an ambulance which, on the evidence, only arrived after police officers arrived on the scene and “expedited” the call to the ambulance control room .
” 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 Provide additional education and support to all call takers involved in the incident.
Verbatim wording from the response “The investigation determined that the root cause of the failings emanated from one individual member of staff. Specifically the Clinical Contact Centre Allocator and I can confirm that the Trust has acted upon these findings in relation to that individual who is currently being managed in line with the Trust’s relevant policies and procedures regarding the failings identified. I can assure you that the Trust views matters of this nature extremely seriously and in addition to the above, all the call takers involved in this incident have also received additional education and support.” Source location 2016-0461-Response-by-Welsh-Ambulance-Service
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 ambulance was allocated one minute before South Wales Police contacted the control centre, rather than after police expedited the call.
Verbatim wording from the response “One minute after allocation of this vehicle, a third call was received in relation to this incident from South Wales Police informing our Clinical Contact Centre that they had received a call for this patient. The Trust call taker who had remained in contact with the caller identified that a police officer arrived at the scene at approximately 02:00hrs.” Source location 2016-0461-Response-by-Welsh-Ambulance-Service
Open published response
Concerns raised 6 Delays in the provision of ambulance assistance View source Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability View source Failure to ensure emergency clinicians know what pain relief has already been provided View source Unavailability of senior clinicians for overnight second opinions View source Failure to rectify previously identified patient handover delays View source Lack of emergency clinicians’ awareness of overnight patient-discharge policies View source See 3 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.
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AI-generated summary
Clive Harold Turner · 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
Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.
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 the provision of ambulance assistance
Wider context from the report “1. That there were significant delays in the provision of assistance to Mr Turner by the Welsh Ambulance Service
” 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 Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
Wider context from the report “2. That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls . Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” 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 emergency clinicians know what pain relief has already been provided
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight.
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner.
” 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 senior clinicians for overnight second opinions
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight.
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner .
” 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 rectify previously identified patient handover delays
Wider context from the report “3. It is of considerable concern to me that item 2 above is a direct repeat of a concern which I raised in a previous Regulation 28 report following the death of Mr Frederick Pring in March 2013, twelve months before that of Mr Turner, the joint response of WAST and BCUHB being received exactly one week before Mr Turner's 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 Lack of emergency clinicians’ awareness of overnight patient-discharge policies
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight .
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner.
” Open source report
Concerns raised 2 Failure to factor critical clinical information into operator advice View source Failure of the ambulance service computer programme to take account of critical clinical information 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
Winston Llewellyn Johns · 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
Winston Llewellyn Johns was found unrousable with a blood sugar level of 1.4 during a 999 call. He was advised to undergo CPR, sustained a sternum fracture and multiple rib fractures, and later died in hospital from pneumonia caused by those fractures. The concerns were that the low blood sugar information was not factored into the advice and that the ambulance service’s computer programme contributed to CPR being incorrectly advised.
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 factor critical clinical information into operator advice
Wider context from the report “(1) Mr Johns son clearly confirmed the low blood sugar at the beginning of the call. This critical important information was not factored into the advice provided to him by the operator.
” 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 ambulance service computer programme to take account of critical clinical information
Wider context from the report “(2) The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations