6 May 2026 Lisa Jayne Townsend · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre View source Delays in seeking specialist advice and transferring patients to a tertiary centre View source
Responses linked to these concerns
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AI-generated summary
Lisa Jayne Townsend · 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
Lisa Jayne Townsend had abdominal pain and was diagnosed with cholecystitis and pancreatitis in late September 2024. Her gallbladder surgery was delayed and, during the operation on 1 October 2024, an injury was sustained to the bile duct; subsequent attempts to rectify it were unsuccessful. She later developed chronic sepsis and died on 20 March 2025. The report identified multiple delays and issues in her care, including the bile duct injury, as contributing to her death.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters . There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking specialist advice and transferring patients to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters. There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” 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 Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.
Verbatim wording from the response “As a result, the NHS in Wales has undertaken appropriate and proportionate action in response to your report findings and I hope this resolves your concern. My officials will also ensure the lessons relating to this case are shared with other health boards to inform their pathway arrangements.” Source location Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.
Verbatim wording from the response “I note that both health boards named in your report have now responded. These responses outline the steps each organisation has taken to improve understanding among the clinical teams about the delivering this pathway of care. Both health boards have also reported what action they have taken to improve referral and transfer arrangements between their organisations.” Source location Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
Open published response
Concerns raised 1 Lack of standardised crash trolleys across hospital settings View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
SUMMER RAE MANT · 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
Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised crash trolleys across hospital settings
Wider context from the report “During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley , and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups .
Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate , to minimise confusion at a time critical moment.
” 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 Reduce variation in adult and paediatric crash trolley layouts while ensuring adherence to Resuscitation Council UK guidelines.
Verbatim wording from the response “The Welsh Government will require NHSP&I to convene a group of resuscitation experts from Wales to review whether any medicines other than those on the Resuscitation Council UK’s standard list should be available on all crash trolleys in hospitals. The group will undertake work to reduce variation in crash trolley layout for both adults and paediatrics, ensuring adherence to Resuscitation Council UK guidelines.” Source location Response from Department for Health and Social Care
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 Select standard medicine preparations and establish a single all-Wales supplier contract to ensure availability, standardised packaging and branding on crash trolleys.
Verbatim wording from the response “This group will also work with the All Wales Drug Contracting Committee to select the most appropriate preparation of each of these medicines to be stocked on crash trolleys and ensure they are all available to all health boards and trusts through a single all-Wales contract with suppliers. This will ensure standardised packaging and branding of products on crash trolleys for any products where this is not already the case. This approach will ensure that procurement decisions take account not only of cost but also human factors that may influence usability in emergency situations, alongside safety, standardisation, and supply chain resilience.” Source location Response from Department for Health and Social Care
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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 Direct health boards and trusts to use only nationally procured standardised crash-trolley products and follow the agreed layout.
Verbatim wording from the response “The Welsh Government will direct health boards and trusts to only use nationally procured standardised products on crash trolleys and follow the agreed layout.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 3 Significant delays in hospital ambulance handover View source Limited social care provision affecting patient flow View source Delays in emergency ambulance arrival during periods of significant demand 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
Angela Frances Darlow · 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
Angela Frances Darlow suffered a stroke at home on 6 January 2025, but an ambulance arrived 23 hours and 20 minutes later. She was diagnosed with an extensive left middle cerebral artery infarct, was not suitable for thrombectomy because of the delay, and died in hospital on 7 June 2025. The principal concern was the prolonged ambulance delay, in the context of high demand, hospital handover delays, patient flow and limited social care provision, resulting in lost opportunities for investigation and potential treatment.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Significant delays in hospital ambulance handover
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend. The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented. This is reflected by the 23 hour and 20 minute delay in ambulance arriving.
There were significant hospital handover delays at the time which added to the demand on the Trust .
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision. People are dying due to these issues and yet we are no closer to improvement.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Limited social care provision affecting patient flow
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend. The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented. This is reflected by the 23 hour and 20 minute delay in ambulance arriving.
There were significant hospital handover delays at the time which added to the demand on the Trust.
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision . People are dying due to these issues and yet we are no closer to improvement.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency ambulance arrival during periods of significant demand
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend . The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented . This is reflected by the 23 hour and 20 minute delay in ambulance arriving .
There were significant hospital handover delays at the time which added to the demand on the Trust.
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision. People are dying due to these issues and yet we are no closer to improvement.
” Open source report
3 Feb 2026 Lyn Maher · Prevention of Future Deaths report South Wales Central
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Concerns raised 3 Limited access for community pharmacists to patients’ drug histories and recent test results View source Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person View source Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing 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
Lyn Maher · 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
Lyn Maher, aged 79, was prescribed clarithromycin while taking simvastatin and was not advised to stop the statin. She was admitted to hospital, where the contraindicated co-ingestion was not identified, the statin continued, and rhabdomyolysis was missed; she died following cardiac arrest due to hyperkalaemia on 23 January 2024. The concerns included confusion among community pharmacists about clinical checks and confidentiality, and their limited access in Wales to relevant drug history and test results.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Limited access for community pharmacists to patients’ drug histories and recent test results
Wider context from the report “(3) I am concerned that community pharmacists in Wales only have very limited access to the Welsh Clinical Portal , where they can see relevant drug history and recent test results , which would enable them to properly and safely counsel patients to stop contraindicated drugs (here simvastatin with clarithromycin) but applicable more widely. I heard evidence that access to such information is available routinely in English pharmacies, but only in exceptional circumstances in Wales. I have no understanding of why this is the case.
(4) Here, had either community pharmacist had access to Lyn’s drug history, they would have noted the contraindication and either told Lyn, her representative or written on the pharmacy bag that she was to stop the simvastatin. This likely would have changed the outcome for Lyn.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person
Wider context from the report “(2) I am concerned that there is confusion amongst community pharmacists in Wales around the conflict between the expectation of safe prescribing/dispensing and patient confidentiality (when someone other than the patient collects the medication) .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing
Wider context from the report “(1) Evidence was heard that 2 separate community pharmacists did not tell Lyn, (nor pass a message via her family who collected the tablets), that she must stop taking simvastatin during the course of the clarithromycin, required for her chest infection. The pharmacists did not know she was taking simvastatin. I am concerned that there is confusion and a variety of opinion amongst community pharmacists around the extent of the expectation or duty to perform ‘clinical checks’ to enable safe prescribing and what that practically entails .
” Open source report
1 Oct 2025 Milos JANKOVIC · Prevention of Future Deaths report South Wales Central
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Concerns raised 4 Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy View source Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders View source Lack of recall or audit for patients with Barrett’s View source Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance 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
Milos JANKOVIC · 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
Milos JANKOVIC had been diagnosed with Barrett’s Oesophagus in 2014 but was lost to follow-up surveillance after bowel cancer took priority. In 2020, he developed symptoms and was found to have brain metastases from primary oesophageal cancer. Concerns included inadequate processes for Barrett’s surveillance, particularly in primary care, and the absence of recall or prescribing prompts to identify patients needing surveillance or endoscopy.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy
Wider context from the report “(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication , or whether they have previously been diagnosed with the condition and ought to be under surveillance.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders
Wider context from the report “(1) There are two cases that have recently come to my attention within the Cardiff area where patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from oesophageal cancers;
(2) There are inadequate processes in place to address this lacuna , particularly in primary care where a patient may not be a regular attender ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of recall or audit for patients with Barrett’s
Wider context from the report “(3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not currently benefit from such a recall exercise/audit , even though it is well-established to be a pre-cancerous condition;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance
Wider context from the report “(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance .
” 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 Secondary care should continue managing Barrett’s Oesophagus surveillance recalls; GP recalls or prompts would duplicate responsibilities and cause confusion.
Verbatim wording from the response “In terms of recalling people with Barrett’s Oesophagus for surveillance procedures, it is the secondary care team which manages this process. The need for surveillance is added to a patient’s record by the patient administration system used by the health board. Health boards operate standardised recall procedures and follow-up procedures for non-responders to invite people for their surveillance appointments.” Source location Response from Health and Social Services of Wales
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Welsh Government cannot investigate surveillance management because it lacks access to health-board records, systems and processes, and lacks the relevant power and expertise.
Verbatim wording from the response “It is with regret that I am unable to comment on whether such factors may have played a role in the death of Mr Jankovic. The responsibility for the operational delivery of the surveillance list rests with the health board concerned for his treatment – the Welsh Government has no access to health board records or digital systems and processes. The power and expertise to investigate the circumstances of Mr Jankovic’s death – and that of the other case you refer to – and the processes involved in managing the surveillance, lie with the health board.” Source location Response from Health and Social Services of Wales
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant health board is responsible for investigating surveillance-list management and strengthening records and processes to prevent future deaths.
Verbatim wording from the response “It is with regret that I am unable to comment on whether such factors may have played a role in the death of Mr Jankovic. The responsibility for the operational delivery of the surveillance list rests with the health board concerned for his treatment – the Welsh Government has no access to health board records or digital systems and processes. The power and expertise to investigate the circumstances of Mr Jankovic’s death – and that of the other case you refer to – and the processes involved in managing the surveillance, lie with the health board.” Source location Response from Health and Social Services of Wales
Open published response
18 Sep 2025 Pamela SINGH · Prevention of Future Deaths report South Wales Central
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Concerns raised 7 Delays in recognising acute deterioration in people with learning disabilities View source Delays in responding to acute deterioration in people with learning disabilities View source Pneumonia as the most common cause of avoidable deaths among people with learning disabilities View source Delays in escalating acute deterioration in people with learning disabilities View source Lack of familiarity with the use of an acute deterioration recognition tool in Wales View source Increased mortality risk among people with learning disabilities View source Lack of a specific practice tool for recognising, escalating and responding to potential acute deterioration in people with learning disabilities View source See 4 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
Pamela SINGH · 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 Singh died of pneumonia on 29 May 2022 after signs and symptoms had progressed for three days and were not recognised by family and professional care staff until after she went into cardiac arrest. The principal concerns were delayed recognition and response to acute deterioration in a person with a learning disability, and the absence of a specific practice tool to support recognition, escalation and response.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising acute deterioration in people with learning disabilities
Wider context from the report “(4) Delays in recognising , escalating and responding to an acute deterioration is a significant factor in avoidable deaths of people with a Learning Disabilities;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to acute deterioration in people with learning disabilities
Wider context from the report “(4) Delays in recognising, escalating and responding to an acute deterioration is a significant factor in avoidable deaths of people with a Learning Disabilities;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Pneumonia as the most common cause of avoidable deaths among people with learning disabilities
Wider context from the report “(3) The most common cause of avoidable deaths in people with a Learning Disability is pneumonia ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating acute deterioration in people with learning disabilities
Wider context from the report “(4) Delays in recognising, escalating and responding to an acute deterioration is a significant factor in avoidable deaths of people with a Learning Disabilities;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of familiarity with the use of an acute deterioration recognition tool in Wales
Wider context from the report “(6) Neither the GP, Social Worker, or commissioned care provider were familiar with any such tool being used in Wales notwithstanding a recommendation in The Learning Disabilities Mortality Review (LeDeR) Programme Annual Report 2019 to "Adapt (and then adopt) the National Early Warning Score 2 regionally, such as the Restore2TM in Wessex, to ensure it captures baseline and soft signs of acute deterioration in physical health for people with learning disabilities"
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Increased mortality risk among people with learning disabilities
Wider context from the report “(2) The evidence heard from a Learning Disability Psychiatrist and expert in Critical Care was that people with a Learning Disability generally have a significantly increased mortality risk ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific practice tool for recognising, escalating and responding to potential acute deterioration in people with learning disabilities
Wider context from the report “(5) Family and professional care staff did not have any specific practice tool to help them recognise, escalate and ensure a response to concerns about signs of a potential acute deterioration ;
” Open source report
12 Sep 2025 Gareth Idris Johnson · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure of safeguards for moving patients requiring critical care during times of pressure View source Lack of adequate hospital building maintenance View source Insufficient Critical Care capacity for patient volumes 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
Gareth Idris Johnson · 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
Gareth Idris Johnson attended hospital with a bilateral pulmonary embolism and underwent catheter-directed thrombolysis. He later died at University Hospital of Wales from complications following the procedure. The report identified suboptimal post-operative anticoagulation management, including a lack of clarity about the appropriate heparin level, and raised concerns about transferring critical-care patients to PACU because of building maintenance, capacity pressures and infrastructure risks.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure of safeguards for moving patients requiring critical care during times of pressure
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate hospital building maintenance
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient Critical Care capacity for patient volumes
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Cardiff and Vale University Health Board to prioritise estate investment using the capital prioritisation exercise.
Verbatim wording from the response “It is recognised there are many areas of the UHW estate that require significant investment. My officials are working closely with colleagues from Cardiff and Vale UHB about the priority areas for investment informed by a recent capital prioritisation exercise.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £0.750 million funding for a detailed condition survey of the University Hospital of Wales buildings.
Verbatim wording from the response “Specific funding (£0.750m) has been made available to Cardiff and Vale UHB to complete a detailed condition survey of the main buildings on the UHW site to ensure future investment is appropriately targeted. This work will inform short-term investments and whether the buildings are suitable for significant refurbishment in the future.” Source location Response from Department for Health and Social Care
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 Write to Cardiff and Vale University Health Board to confirm clinical governance and safe clinical cover for future critical-care-unit maintenance.
Verbatim wording from the response “2) To write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place to provide safe care during future planned maintenance of the critical care unit.” Source location Response from Department for Health and Social Care
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 business case to refurbish the intensive therapy unit at the University Hospital of Wales.
Verbatim wording from the response “1) Officials met Cardiff and Vale UHB on 15 October with NHS Shared Services Partnership-Specialist Estate Services (NWSSP-SES) to discuss the infrastructure issues at the ITU, critical care and theatres departments at the University Hospital of Wales. A business case is being developed to refurbish the ITU. Due to a lack of available space to relocate patients and the nature of the work involved, this work will likely take a number of years to complete.” Source location Response from Department for Health and Social Care
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 Write to selected health boards, including Cardiff and Vale University Health Board, requesting responses to the critical care network estate census.
Verbatim wording from the response “3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning.” Source location Response from Department for Health and Social Care
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 Consider the critical care census report to inform Welsh Government capital investment plans and health board planning.
Verbatim wording from the response “3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning.” Source location Response from Department for Health and Social Care
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 existing estate was not the primary cause of the death, although estate improvements and resulting patient relocation contributed to it.
Verbatim wording from the response “There are plans being explored for further capital investment at the University Hospital of Wales. While the condition of the existing estate was not the primary cause of Mr Johnson’s death, the need to make estate improvements led to the relocation of patients, which was a contributory factor. I hope the actions I have set out above will result in robust measures being put in place to manage patient moves in the future.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Day-to-day operation and management of the hospital site and services remain the statutory responsibility of Cardiff and Vale University Health Board.
Verbatim wording from the response “There are longer term plans being reviewed and considered by the health board for the redevelopment of the University Hospital of Wales site. This response focuses on the short and medium-term actions I will be seeking the health board to review at the site to address patient safety and ensure the continuity of healthcare services to the local population. The day-to-day operation and management of the site and the healthcare services provided remains the statutory responsibility of Cardiff and Vale University Health Board (UHB). There are also actions, which will be highlighted to other health boards in Wales.” Source location Response from Department for Health and Social Care
Open published response
13 Jun 2025 Valerie HILL · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Excessive ambulance-to-emergency-department handover delays View source Failure to align ambulance rostering assumptions with hospital handover performance View source Failure of health board plans to improve ambulance handover timeliness View source Inadequate health and social care system leadership response to ambulance handover pressures View source Insufficient escalation of ambulance handover delays across health boards View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valerie HILL · 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
Valerie HILL died on 11 March 2022 at Royal Glamorgan Hospital after a fall at Ty Bargoed Care Home led to a periprosthetic femur fracture; pneumonia, COPD and frailty of old age were also recorded. She waited on the floor for over 14 hours for an ambulance, and concerns were raised about inadequate care-home risk assessments, prolonged ambulance handover times, patient-flow systems and continuing system-wide delays in access to emergency care.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Excessive ambulance-to-emergency-department handover delays
Wider context from the report “(1) On 17.2.22 you wrote (then as Minister for Health & Social Care) to the Chairs of all Health Boards in Wales, and inter alia, alerted the same to the following: -
“The volumes of people waiting excessive periods for transfer from ambulance vehicles to the care of staff in Emergency Departments, in particular, has reached intolerable levels ….I am concerned about the level of tolerance to such delays a require you to take greater ownership of this issue as a priority….the current situation cannot continue”
The then, and continuing NHS Deputy Chief Executive ████████ gave evidence at the Inquest. He indicated that CTMUHB had been in Targeted Intervention since October 2022 (2.5 years) and he hadn’t seen significant improvement in relation to 15 minute or 1hr handovers .
In answer to my final question to him as to whether a situation akin to that which Valerie faced on 7 March 2022 could happen again today, he accepted that that was a fair conclusion and that the same risks remain in the system
In the three years since Valerie’s death you have received multiple Prevention of Future Death Reports from myself and fellow Coroner’s in Wales highlighting the devastating outcomes attributable to delays in conveying acutely unwell patients to hospital/ambulance handover delays.
Those risks continue and are of acute concern to myself and my Coronial colleagues throughout Wales.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to align ambulance rostering assumptions with hospital handover performance
Wider context from the report “(2) Despite some relaxation in the guidelines set by the Welsh Ministers in relation to ambulance handover delays/timings in 2024, WAST continues to adopt the 15 minute handover expectation/assumption for their rostering . Yet I received evidence that hospitals across Wales are only delivering this expectation around 10-20% of the time .
My concern is that this disconnect is having a significant effect upon how the system for conveying acutely ill patients in the community to hospital is operating and changes are indicated to address this system dysfunctionality.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure of health board plans to improve ambulance handover timeliness
Wider context from the report “(4) In your response to my Prevention of Future Death Report in relation to Lynda Blackmore (PFD and your response annexed) you indicated inter alia:-
“For the past two iterations of the framework, I have been explicitly clear of my expectation that Health Boards prioritise plans to improve timeliness of ambulance patient handover to free up ambulance clinicians to respond to patients in the community…I have also set a priority for improvement of patient flow.”
My concern is that the same has not led to any discernible improvement in ambulance handover delays & that consideration might be given for a review of the level of escalation that not only applies on this issue to CTMUHB but also those Health Boards across Wales.
I was repeatedly referenced at the Inquest by CTMUHB that their performance in many areas relating to ambulance handover times was not “the worst in Wales”.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Inadequate health and social care system leadership response to ambulance handover pressures
Wider context from the report “(3) On 17.2.22 ████████ Chief Executive of NHS Wales wrote to you as then Minister for Health and Social Services & in relation to the then acute concerns she had over delayed ambulance handovers indicated as follows:-
“A health and social care system leadership response is required to current operational pressures on a par to the Covid-19 response ”
████████ in his oral evidence confirmed that the response had not been on a par with the Covid-19 response
My concern is that the prevalence and extent of such delays has become beyond intolerable and is leading to many acutely unwell patients in the community waiting for such prolonged periods for emergency care, dying directly & indirectly as a consequence.
The balance of risk in the system appears to be borne disproportionately by the patients in that category & consideration ought to be given to redressing 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient escalation of ambulance handover delays across health boards
Wider context from the report “(4) In your response to my Prevention of Future Death Report in relation to Lynda Blackmore (PFD and your response annexed) you indicated inter alia:-
“For the past two iterations of the framework, I have been explicitly clear of my expectation that Health Boards prioritise plans to improve timeliness of ambulance patient handover to free up ambulance clinicians to respond to patients in the community…I have also set a priority for improvement of patient flow.”
My concern is that the same has not led to any discernible improvement in ambulance handover delays & that consideration might be given for a review of the level of escalation that not only applies on this issue to CTMUHB but also those Health Boards across Wales .
I was repeatedly referenced at the Inquest by CTMUHB that their performance in many areas relating to ambulance handover times was not “the worst in Wales”.
” 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 Establish a National Handover-45 Taskforce to support system-wide ambulance handover improvements.
Verbatim wording from the response “The independent Getting it Right First Time (GIRFT) and Ministerial Advisory Group on NHS Performance and Productivity report also underscored the need for change. The Cabinet Secretary for Health and Social Care has announced a National Handover-45 Taskforce to support health boards and WAST to deliver system-wide improvements to improve ambulance handover.” Source location Response from The First Minister for Wales
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 Compile evidence on effective ambulance handover strategies to inform an improvement programme and readiness assessment.
Verbatim wording from the response “The taskforce will use the NHS Performance and Improvement review as a foundation and compile comprehensive evidence about effective strategies for improving ambulance patient handover. This will inform the development of an improvement programme and a readiness assessment.” Source location Response from The First Minister for Wales
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 Assess NHS Wales readiness to deliver ambulance handovers within 15 minutes and no later than 45 minutes.
Verbatim wording from the response “It will play a key role in assessing and supporting the readiness of NHS Wales to deliver every ambulance patient handover within 15 minutes as far as possible, but always within 45 minutes.” Source location Response from The First Minister for Wales
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 Share successful local strategies, cultures, processes and models with all health boards.
Verbatim wording from the response “There have been some encouraging signs of improvement because of local strategies, the work of the Six Goals for Urgent and Emergency Care programme, and the Wales-wide focus on reduced delayed hospital discharges. These approaches will be shared with all health boards and the taskforce will also draw on other successful cultures, processes and models from across the UK.” Source location Response from The First Minister for Wales
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and support high-impact community pathways, effective emergency-department processes, and patient-flow and discharge processes.
Verbatim wording from the response “The taskforce will develop and support delivery of high-impact clinical pathways in the community; support the delivery of effective evidence-based emergency department processes and support the delivery of evidence-based processes to improve the flow of patients from emergency departments to wards and optimise discharge.” Source location Response from The First Minister for Wales
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 Seek urgent assurance from each health board on actions supporting handover-guidance compliance and reduced delays.
Verbatim wording from the response “A review of health board compliance was commissioned in quarter four of 2024-25 and completed in March 2025 by NHS Performance and Improvement. A report containing learning and key themes for health boards to consider was shared by Welsh Government on 18 June 2025. A copy is attached at annex A.” Source location Response from The First Minister for Wales
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 Run 30-, 60- and 90-day rapid improvement events with health-board and operational leaders.
Verbatim wording from the response “The taskforce will support health boards and WAST through a series of rapid improvement events over a 30, 60 and 90-day period. These will bring together senior clinical and operational leaders at a health board level with a focus on high-impact pathways, emergency department processes, improving patient flow and encouraging clinical ownership of actions.” Source location Response from The First Minister for Wales
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 Commission and complete a review of health-board compliance with ambulance patient handover guidance.
Verbatim wording from the response “The Cabinet Secretary for Health and Social Care has been clear with health boards about his expectation for improvement in the timeliness of ambulance patient handovers. All health boards are expected to deliver the Ambulance Patient Handover Guidance, which has been established as one of the five priorities (‘enabling actions’) for urgent and emergency care in the NHS planning framework for 2025-26. It also features as part of the health board chairs’ objectives as a marker of performance.” Source location Response from The First Minister for Wales
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 Follow up health-board progress through Integrated Quality Planning and Delivery meetings.
Verbatim wording from the response “Welsh Government officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects from the report to support compliance with the handover guidance and work towards delivery of no delays in excess of 45 minutes by quarter three of 2025-26. Progress will be followed up by officials and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings with health boards.” Source location Response from The First Minister for Wales
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Welsh Ministers set strategic expectations but do not deliver health services; health boards and NHS trusts deliver services within the national policy framework.
Verbatim wording from the response “Welsh Ministers set the strategic expectations for health and care services and hold health bodies accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.” Source location Response from The First Minister for Wales
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health boards are responsible for ensuring ambulance handovers occur reliably, in clinical priority order and within 15 minutes.
Verbatim wording from the response “The Welsh Government’s clear expectation is that when someone is conveyed to hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.” Source location Response from The First Minister for Wales
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation WAST is responsible for managing and delivering emergency ambulance services, while the JCC plans, secures and commissions them.
Verbatim wording from the response “The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 established the Welsh Ambulance Services University National Health Service Trust (WAST). ████████” Source location Response from The First Minister for Wales
Open published response
Concerns raised 3 Delays in ambulance attendance View source Lack of social care and community hospital capacity for discharge and onward bed availability View source Delays in hospital handover of ambulances View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jeanette Sidlow Beech · 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
Jeanette Sidlow Beech, who had a history of alcohol withdrawal-related seizures, became unwell at home on 2 August 2024 and died there on 3 August 2024 after suffering a seizure and cardiac arrest. An ambulance took 15 hours and 13 minutes to attend, by which time resuscitation efforts were unsuccessful. The report raises concerns about ambulance response and hospital handover delays, linked to wider pressures involving hospital capacity, social care and community hospital provision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette , by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.
b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.
c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST.
d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons.
e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours.
f. The issues identified are pertinent to WAST, the Health Board and Local Authorities.
g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of social care and community hospital capacity for discharge and onward bed availability
Wider context from the report “a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.
b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.
c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST.
d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons.
e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours . Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours.
f. The issues identified are pertinent to WAST, the Health Board and Local Authorities.
g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover of ambulances
Wider context from the report “a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.
b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays .
c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST.
d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons.
e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours .
f. The issues identified are pertinent to WAST, the Health Board and Local Authorities.
g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists.
” 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 Compile evidence on effective ambulance handover strategies and develop an improvement programme and readiness assessment.
Verbatim wording from the response “The taskforce will use the NHS Performance and Improvement review as a foundation and will compile comprehensive evidence on effective strategies for improving ambulance patient handover. This will inform the development of an improvement programme and a readiness assessment.” Source location Response from Welsh Government
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 Monitor health-board progress against ambulance handover actions through Integrated Quality Planning and Delivery meetings.
Verbatim wording from the response “My officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects in this report to support compliance with the handover guidance and work towards delivery of no delays of more than 45 minutes by quarter three in 2025-26. Progress will be closely monitored by the Welsh Government and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings.” Source location Response from Welsh Government
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 the compliance review of ambulance patient handover guidance and share its findings with health boards.
Verbatim wording from the response “To support health boards, my officials arranged a review of compliance with the ambulance patient handover guidance during the last quarter of 2024-25, which was completed by March 2025 by NHS Performance and Improvement. A report detailing the findings and key themes for health boards was shared on 18 June. A copy is attached at annex A.” Source location Response from Welsh Government
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 Seek urgent assurance from each health board on actions to comply with ambulance handover guidance.
Verbatim wording from the response “My officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects in this report to support compliance with the handover guidance and work towards delivery of no delays of more than 45 minutes by quarter three in 2025-26. Progress will be closely monitored by the Welsh Government and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings.” Source location Response from Welsh Government
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 Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.
Verbatim wording from the response “We have made an additional £2.7m available to the health board this year to support delivery of local improvement plans. This is part of £35.5m to support the health board and the North Wales Regional Partnership Board to safely manage more people in the community; to avoid ambulance transport and admission to hospital; and deliver integrated solutions with social care services to improve patient flow through hospitals. The impact made by the region is being closely monitored.” Source location Response from Welsh Government
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 Support health boards and WAST to improve ambulance handover performance toward 15-minute handovers and a 45-minute backstop.
Verbatim wording from the response “It will support all health boards and WAST to improve handover performance, working towards delivery of a standard ambulance patient handover within 15 minutes, with a backstop of 45 minutes.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the clinically led National Handover-45 Taskforce.
Verbatim wording from the response “To further drive improvements, I announced on 30 June, a clinically-led National Handover-45 Taskforce – the details are set out in this Written Statement.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Welsh Ministers set strategic expectations but are not responsible for delivering health services.
Verbatim wording from the response “Welsh Ministers set the strategic context and expectations for health and care services in Wales and hold NHS organisations accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation WAST is responsible for delivering emergency ambulance services, while the JCC commissions those services.
Verbatim wording from the response “The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 established the Welsh Ambulance Services University National Health Service Trust (WAST). Article 3 delegates the function of managing the ambulance service to WAST.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health boards are responsible for planning, commissioning and delivering local health services within the national policy framework.
Verbatim wording from the response “Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their local areas, in line with the national policy framework set by Welsh Ministers.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health boards are responsible for ensuring ambulance handovers occur reliably and that receiving hospitals have sufficient capacity.
Verbatim wording from the response “The Welsh Government’s policy expectation of health boards is that when a patient is conveyed to a hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.” Source location Response from Welsh Government
Open published response
23 Apr 2025 Martin Robert SAUNDERS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Risk of road traffic collisions from vehicles turning right across the carriageway from the layby View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Robert SAUNDERS · 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
Martin Robert Saunders, aged 48, died at the scene after his motorbike collided with a coach making a right turn from a layby on the A4059 New Road, Mountain Ash, on 17 June 2023. The report raised concern that reduced visibility, speed and vehicles turning right across the carriageway from the layby created a risk of future deaths along this route.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions from vehicles turning right across the carriageway from the layby
Wider context from the report “The collision occurred on the A4059, New Road, Mountain Ash near the exit of a parking bay located on the east side of the carriageway. The parking area can be busy. At the time of the collision, the speed limit on the road was 60 mph and there was no prohibition on making right turns from the layby. The combination of reduced visibility due to the bends in the road, speed and right turns across the carriageway increases the risk of road traffic collisions.
Changes are in progress to reduce the maximum speed limit but even allowing for this, I remain concerned there is a risk of future deaths occurring along this route unless action is taken, due to vehicles turning right across the carriageway from the layby on this stretch of road.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommendations concerning the A4059 should be addressed to RCTCBC, which is responsible as the local highway authority.
Verbatim wording from the response “The Welsh Government and its Ministers are the Highway Authority responsible for the Motorway & Trunk Road Network in Wales.” Source location Response from Welsh Government
Open published response
18 Feb 2025 Jeffrey Martin Tyler · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to revise ambulance priority when a patient is deteriorating and in extremis View source Inability of a patient who is alone to inform the ambulance service of deterioration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jeffrey Martin Tyler · 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
Jeffrey Martin Tyler called emergency services with chest pains and difficulty breathing, but his condition deteriorated while he was alone at home. An ambulance arrived several hours later, and his death was confirmed by paramedics on 20 February 2024. The substantive concern was that, despite his deterioration and being alone and in extremis, the emergency call remained categorised as Amber 1, with a reported waiting time of between 5 and 7 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to revise ambulance priority when a patient is deteriorating and in extremis
Wider context from the report “In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event . Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated.
Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1 . The waiting time was between 5 and 7 hours.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Inability of a patient who is alone to inform the ambulance service of deterioration
Wider context from the report “In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated .
Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours.
” 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 Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.
Verbatim wording from the response “I hold the Chair of WAST to account for oversight of the delivery of those expectations through regular meetings. Officials also hold the Chief Executive Officer and his executive team to account through bimonthly integrated quality planning and delivery (IQPD) meetings where progress against key performance targets is scrutinised and assurance on the quality and safety of services is sought. I have asked officials to seek assurance on the process of categorisation of calls and steps taken by the Trust to ensure service users receive the right response for their clinical need at the next IQPD meeting to be held on 24 April 2025.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.
Verbatim wording from the response “Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.
Verbatim wording from the response “Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.
Verbatim wording from the response “However, it is important to note, that the Welsh Ministers are not responsible for the delivery of health services in Wales. Instead, Local Health Boards (LHBs) are responsible for planning, commissioning and delivering services for the population of its area and NHS Trusts are responsible for the delivery of services across Wales within the national policy framework set by the Welsh Ministers.” Source location Response from Welsh Government
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 WAST is responsible for operational emergency ambulance call categorisation and is best placed to respond to required action.
Verbatim wording from the response “The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 establishes the Welsh Ambulance Services University National Health Service Trust (WAST). Article 3 delegates the function of managing the ambulance service to WAST.” Source location Response from Welsh Government
Open published response
7 Feb 2025 Ian Augustus Jones · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Accessibility of electric motors and parts enabling conversion of pedal bicycles into high-powered throttle-controlled scooters 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
Ian Augustus 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
Ian Augustus Jones died at University Hospital Wales, Cardiff, on 29 October 2022 from a traumatic brain injury sustained after the electrically motorised bicycle he was riding without a helmet collided with a pavement bollard. The report raised concern about the accessibility of electric motors and parts that can convert a pedal bicycle into a high-powered, throttle-controlled scooter capable of high speeds and rapid acceleration, posing a danger to riders and other members of the public.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Accessibility of electric motors and parts enabling conversion of pedal bicycles into high-powered throttle-controlled scooters
Wider context from the report “(1) The accessibility of electric motors and parts that can be easily used to convert a normal pedal bicycle into a high powered, throttle controlled scooter capable of high speeds with rapid acceleration that can pose a danger to the rider and to other members of the public.
” Open source report
17 Jan 2025 Donald John Drummond MITCHELL · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Unsafe cyclist conditions along the A48 between Pyle and Ewenny 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
Donald John Drummond MITCHELL · 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
Donald John Drummond Mitchell was cycling home from work on 17 December 2020 when he was struck by a vehicle on the A48 and suffered catastrophic head injuries. The concern was that the road between Ewenny and Pyle had a history of fatal and serious collisions, including collisions involving cyclists, and lacked an active travel route or modifications specifically supporting cyclist safety, creating a risk of future deaths unless action was taken.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Unsafe cyclist conditions along the A48 between Pyle and Ewenny
Wider context from the report “(1) Between 2015 and 2024, along the A48 between Pyle and Ewenny which is a 5.75 mile stretch of road, there have been 4 fatal collisions and 8 serious collisions. Of these collisions, 5 involved cyclists.
(2) On the basis of the evidence of the nature of the road between Ewenny roundabout and Pyle roundabout (which varies between a single and dual carriageway), the speed limit in place (which varies between 40mph and up to national speed limit), the current absence of an active travel route or modifications to the route to specifically cater for cyclist safety , along with the data available as to the number of collisions along this route relating to cyclist, I remain concerned that there is a risk of future deaths occurring along this route unless action is taken .
” Open source report
Concerns raised 2 Failure to preserve fire scenes until all instructed investigations are completed View source Insufficient mandated fire protection for fires starting in individual rooms in rented accommodation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Muhammad Esmael and Naemat Esmael · 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 1 July 2023, a fire started in an upstairs bedroom of a Council-leased property while three-year-old Muhammad Esmael was inside; Muhammad and his father, Naemat Esmael, died in the fire. The concerns included that the two working smoke alarms were not activated by the fire because it was contained in a closed bedroom, and that bedroom items were removed before all investigations were completed, potentially preventing the cause of the fire from being determined.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve fire scenes until all instructed investigations are completed
Wider context from the report “I heard that certain items within the bedroom where the fire started, including a console unit and electrical items, were removed before they could be fully inspected in situ by the Chartered Electrical Engineer instructed to investigate the cause of the fire. I am told that the items were removed by the Crime Scene Investigators from South Wales Police in circumstances where the Fire Service had exercised its powers under section 45 of the Fire and Rescue Services Act 2004 and had commenced an investigation which was aimed at determining the point of origin, cause and behaviour of the fire at ████████. The Chartered Electrical Engineer expert told me that he was unable to provide me with any assistance on the cause of the fire because the items had been removed from the scene and because he had only been able to view photographs. It was this Expert’s opinion that it would have been preferable if the items had remained in position at the property to enable him to inspect them in situ. I am concerned that items were removed from the scene before all inspections were completed and that this may have prevented me and indeed the Fire Service investigators from determining the cause of this fire. I am concerned either that there may not be a sufficiently robust protocol in place between South Wales Police and the Fire Service on preserving a scene to ensure a full investigation takes place and / or that if there is such a protocol it may not have been followed in this instance. If coroners and investigators are unable to determine the cause of a fire because the scene has not been preserved for as long as required to ensure a full in situ investigation by all instructed investigators, then this prevents lessons from being learnt about the cause of a fire which in turn means there is a continuing risk to life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient mandated fire protection for fires starting in individual rooms in rented accommodation
Wider context from the report “I heard evidence during the inquest that two working smoke alarms were not activated by this fire which occurred in a residential Council owned property and which led to the deaths of two individuals. I heard that this may have happened because the fire was contained in a bedroom with the door closed. I heard evidence that Welsh Government legislation (Renting Homes (Wales) Act 2016 implemented by The Renting Homes (Fitness for Human Habitation) Wales Regulations 2022) only requires rented properties to be, inter alia, fitted with two hard wired smoke alarms and that separately, sprinkler systems are only mandated in new build properties or properties undergoing alterations (Domestic Fire Safety (Wales) Measure 2011). I heard that smoke alarms in hallways only safeguard communal areas and the means of escape in a fire and that they do not provide adequate protection to mitigate against the risk to life from fires which start in individual rooms, including bedrooms. I heard that sprinkler systems are expensive for Councils and landlords to fit but that they are very successful in controlling fires and reducing fatalities from fires in properties. I also heard that hard wired smoke alarms are less expensive to fit but would still be beyond the budget of a local Council with a significant property portfolio, which is the case here. I heard that smoke alarms provide the best protection against the risk to life posed by fire in domestic and other properties. I am concerned that only mandating two smoke alarms in rented accommodation means that there is a continuing risk to life from fire in such accommodation.
” 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 Consider the Regulation 28 report alongside independent evaluation findings and use them to decide whether changes to the current regulations are required.
Verbatim wording from the response “Although the Welsh Government keeps all legislation under review, the 2016 Act is additionally subject to a three-year independent evaluation. This is considering all aspects of the legislation and the Phase 1 report has indicated a good awareness of the requirements in the Regulations, with landlords, agents and contract-holders all commenting on the increased provision of smoke alarms and the other preventative measures. Phase 2 of the evaluation is currently nearing completion and Phase 3, which will report in 2025, will consider the overall impact of the 2016 Act, including the Regulations. The findings of your Regulation 28 report will be considered alongside the ongoing findings from the independent evaluation and will inform a decision as to whether any changes to the current regulations are required.” Source location Response from Welsh Government
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 Operational matters concerning scene items and inter-service working are for South Wales Police and Mid and West Wales Fire and Rescue Service.
Verbatim wording from the response “I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.” Source location Response from Welsh Government
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 Welsh Government has no control over operational scene and inter-service matters and cannot take action addressing them.
Verbatim wording from the response “I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.” Source location Response from Welsh Government
Open published response
Concerns raised 2 Delays in responding to Amber 1 emergency calls View source Unavailability of ambulances due to prolonged waits to offload patients at hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Parker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to Amber 1 emergency calls
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances due to prolonged waits to offload patients at hospitals
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor delivery of urgent and emergency care priorities through bi-monthly Integrated Quality, Planning and Delivery meetings.
Verbatim wording from the response “Successful delivery of these plans should support improvements across a range of measures, including the reduction of ambulance patient handover delays contributing to improved ambulance responsiveness. Progress in delivering these priorities is monitored through bi-monthly Integrated Quality, Planning and Delivery meetings between Welsh Government officials, representatives of the NHS Executive and health boards.” Source location Response from Welsh Government
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 Commission development of a community-based falls response framework to reduce unnecessary ambulance responses and emergency department transfers.
Verbatim wording from the response “Additionally, the Welsh Government commissioned the development of a community based falls response framework which was published by the NHS Executive on 30 October 2024 and a national task group established to enable health boards to deliver. The intention is to better support people who have fallen but are not seriously ill or injured, to safely avoid the need for an ambulance response or transport to emergency departments, thus reducing ambulance patient handover delays and improving experience and outcomes.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish national ambulance patient handover guidance setting expectations for relevant NHS organisations and clinicians.
Verbatim wording from the response “More recently, the Welsh Government has developed new ambulance patient handover guidance – published on 29 October 2024 which sets out expectations of the NHS Wales Joint Commissioning Committee, ambulance clinicians and health boards to support improved ambulance patient handover. The NHS Executive will undertake audits of organisations’ compliance with the guidance over the remainder of 2024/2025, and we have been clear that health boards must also undertake their own audits of compliance.” Source location Response from Welsh Government
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 Set annual NHS planning expectations and ambulance handover, patient-flow and delayed-discharge improvement priorities, including a 30% reduction aspiration.
Verbatim wording from the response “The Welsh Government communicates its expectations of health boards and NHS Trusts through an annual NHS planning framework and organisations are expected to produce integrated medium-term plans annually that respond to the priorities set in the NHS planning framework.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging with other UK nations and seek to transfer learning to improve ambulance patient handover performance in Wales.
Verbatim wording from the response “The Welsh Government are monitoring progress very closely and will review lessons learned following completion of the initial 50 days on 31 December 2024 to support sustained implementation of the best practice actions in 2025 and onwards. The Welsh Government also continues to engage regularly with other UK nations to learn lessons about solutions to the ambulance patient handover issue and will be seeking to transfer learning to improve performance in Wales in 2025.” Source location Response from Welsh Government
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 lessons from the winter challenge after its initial 50 days to support sustained implementation of best-practice actions.
Verbatim wording from the response “The Welsh Government are monitoring progress very closely and will review lessons learned following completion of the initial 50 days on 31 December 2024 to support sustained implementation of the best practice actions in 2025 and onwards. The Welsh Government also continues to engage regularly with other UK nations to learn lessons about solutions to the ambulance patient handover issue and will be seeking to transfer learning to improve performance in Wales in 2025.” Source location Response from Welsh Government
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 Launch a 50-day integrated care winter challenge funded by additional Welsh Government funding to accelerate safe alternatives to admission and timely discharge.
Verbatim wording from the response “The Welsh Government has also recently launched a 50-day integrated care winter challenge (‘the challenge’) based on learning from other parts of the UK. The Welsh Government identified ten high-impact and best practice actions for health boards, regional partnership boards and local authorities to deliver between 11 November and 31 December 2024.” Source location Response from Welsh Government
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 Delivering emergency ambulance services in line with commissioning intentions is the ambulance trust’s responsibility.
Verbatim wording from the response “I note you have also written to the Chief Executive of Swansea Bay University Health Board (which is responsible for planning and delivering services based on an assessment of local population need), and the Chief Executive of the Welsh Ambulance Services University NHS Trust (which is responsible for delivering emergency ambulance services in line with commissioning intentions set of it by the NHS Wales Joint Commissioning Committee). The independent responses of the health board and the trust should detail the respective actions taken by each organisation to address your concerns.” Source location Response from Welsh Government
Open published response
26 Jun 2024 Marjorie Joyce Michael · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Delays in ambulance responses to potentially life-threatening emergencies View source Failure to release emergency ambulances from acute hospitals promptly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marjorie Joyce Michael · 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
Marjorie Joyce Michael fell at a residential home and lay on the floor for over 14 hours while waiting for an ambulance. She was taken to hospital on 4 September 2023 and died on 6 September 2023; the inquest recorded hypostatic pneumonia following the fall and long lie, with her death contributed to by the delayed ambulance response. The report raises concerns about continuing delays in ambulance responses, including delays in releasing emergency ambulances from acute hospitals.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance responses to potentially life-threatening emergencies
Wider context from the report “Despite ongoing attempts by Welsh Ambulance Service and Aneurin Bevan University Health Board, the delays in responding to emergency calls are not improving . Witness evidence confirmed the many initiatives undertaken by these services to improve ambulance response times but these continue to be undermined by the delay in releasing emergency ambulances from acute hospitals to attend emergency calls.
Witness evidence also confirmed that despite these initiatives there was no appreciable reduction in the length waiting times for Amber 1 and Amber 2 responses; which are categorised as potentially life-threatening emergencies .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to release emergency ambulances from acute hospitals promptly
Wider context from the report “Despite ongoing attempts by Welsh Ambulance Service and Aneurin Bevan University Health Board, the delays in responding to emergency calls are not improving. Witness evidence confirmed the many initiatives undertaken by these services to improve ambulance response times but these continue to be undermined by the delay in releasing emergency ambulances from acute hospitals to attend emergency calls .
Witness evidence also confirmed that despite these initiatives there was no appreciable reduction in the length waiting times for Amber 1 and Amber 2 responses; which are categorised as potentially life-threatening emergencies.
” 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 Continue monitoring ambulance handover performance and the reduction of delays exceeding one hour.
Verbatim wording from the response “Whilst in escalation, ABUHB is held to account by Welsh Government through normal performance management arrangements such as IQPD and JET meetings. Further oversight is also in place through enhanced monitoring touchpoint meetings chaired by either the Deputy Chief Executive of NHS Wales or the Welsh Government Director of Operations for NHS Wales, as well as quarterly escalation meetings with LHB leads and chaired by the Chief Executive of NHS Wales. This includes a focus on progress made by LHBs on delivering the in-year aspiration to reduce ambulance patient handover delays over an hour in length by 30% by the end of December.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £14 million capital investment to support expansion of the Grange University Hospital emergency department.
Verbatim wording from the response “Finally, following consideration of a business case submitted by ABUHB earlier this year, we have also provided £14m capital investment to support the expansion of the emergency department at the Grange University Hospital site. Improvements are expected to be completed by Spring 2025 and will double the current wait capacity (38) to provide 75 seats in total. There will also be an area dedicated to support the e-triage tool referenced above, with the existing waiting area repurposed to provide a rapid assessment area, both of which will help with timeliness of access – providing the right care and treatment more efficiently.” Source location Response from Welsh Government
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 Set in-year aspirations for local health boards to reduce ambulance handovers exceeding one hour by 30% by December 2024.
Verbatim wording from the response “I remain concerned about the levels of ambulance patient handover delays reported across Wales, and LHBs must improve the timeliness of handover to release ambulance crews to respond to other patients in the community.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide capital funding decisions on WAST vehicle-replacement business justification cases.
Verbatim wording from the response “In terms of procuring ambulance vehicles, WAST submitted a Strategic Outline Programme (SOP) in 2016 that was endorsed by Welsh Cabinet Secretaries for its Vehicle Replacement Programme. The endorsement of the SOP allows WAST to submit Business Justification Cases (BJCs) setting out its vehicle replacement requirements on an annual basis. I will then make a decision on the BJC. Capital funding over the last three years is as follows:-” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional funding to support urgent and emergency care improvements and local programme delivery in Gwent.
Verbatim wording from the response “We have provided an additional £6 million in six goals programme funding over the last two years to drive improvements in urgent and emergency care in Gwent, and the ABUHB will receive a further £2.7m this year. This funding has been used to develop new services and recruit key clinical leadership to oversee the ABUHB’s local programme plan.” Source location Response from Welsh Government
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 Establish and fund the Six Goals programme to support improvements in ambulance handover, patient flow and urgent and emergency care.
Verbatim wording from the response “We established the six goals programme to enable LHBs to deliver on the objectives set out in our strategy, and have allocated an additional £50m in support over the past two years. The annual six goals allocation has increased to £27m in 2024/2025.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide funding for WAST workforce expansion and targeted investment in ambulance clinical triage resources and technology.
Verbatim wording from the response “In addition to core funding, we provided £3m to the WAST in 2022/2023 to enable recruitment of 100 new staff. Since December 2021, there has been a 4.6% increase in WAST’s emergency medical services workforce in the ABUHB area.” Source location Response from Welsh Government
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 Escalate ABUHB to enhanced monitoring and oversee agreed improvement requirements through enhanced monitoring, escalation and performance meetings.
Verbatim wording from the response “Escalation of ABUHB to enhanced monitoring (Level 3)” Source location Response from Welsh Government
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 Local health boards are responsible for planning and delivering ambulance-related health services locally.
Verbatim wording from the response “In the report you ask for an update on details of action taken or proposed by the Welsh Government to improve ambulance responsiveness and prevent future deaths in the Gwent area. Whilst I have a role to set expectations in terms of a strategic direction for health and care services in Wales, and to hold the NHS to account, local health boards (LHBs) remain responsible for planning and delivering these services at a local level to meet the needs of the communities they serve.” Source location Response from Welsh Government
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 WAST and ABUHB are responsible for delivering services on the ground and should provide specific details of their actions.
Verbatim wording from the response “You may wish to write to both organisations directly for further details on specific actions they are taking to improve ambulance responsiveness and prevent future deaths linked to delayed ambulance response, as they are responsible for delivery of services on the ground. I have provided a summary of the actions undertaken by ABUHB and WAST for information below, as reported to us by both organisations through ongoing monitoring arrangements undertaken by Welsh Government officials and the NHS Executive.” Source location Response from Welsh Government
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 NHS Joint Commissioning Committee is responsible for determining funding allocated to the ambulance service.
Verbatim wording from the response “The new NHS Joint Commissioning Committee (NHS JCC) was established on 1 April 2024 and has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services. I will hold the chair of the NHS JCC to account for effective commissioning of emergency ambulance services and achievement of the Ministerial priorities I have set of all organisations from 2024/2025 onwards.” Source location Response from Welsh Government
Open published response
25 Jun 2024 Isobel Lilian Stapleton · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Delays in access to necessary psychotherapy View source Failure to provide mental health practitioners with easy access to all relevant clinical records View source Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital View source Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records View source Unavailability of clinical psychologist access for direct home treatment assessment and treatment in Merthyr Tydfil View source Failure to ensure mental health practitioners are aware of all relevant clinical records 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
Isobel Lilian Stapleton · 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
Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in access to necessary psychotherapy
Wider context from the report “(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health practitioners with easy access to all relevant clinical records
Wider context from the report “(1) Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital
Wider context from the report “(4) The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records
Wider context from the report “(3) Mental health practitioners in Wales currently have no way easily to access NHS England clinical records .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinical psychologist access for direct home treatment assessment and treatment in Merthyr Tydfil
Wider context from the report “(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient . The waiting list for any necessary psychotherapy is months in length.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health practitioners are aware of all relevant clinical records
Wider context from the report “(2) Mental health practitioners may not be aware of the existence of all such records , some of which may be in paper .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Cwm Taf Morgannwg University Health Board to accelerate implementation of electronic mental health patient records.
Verbatim wording from the response “In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.” Source location Response from Welsh Government
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 the business case for introducing and deploying mental health systems across NHS Wales.
Verbatim wording from the response “In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.” Source location Response from Welsh Government
Open published response
22 Feb 2024 Joseph Leonard Scott Cattle · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Delays in hospital handover holding up ambulance resources View source Delays in allocating available ambulance resources to Amber 1 calls View source Insufficient funded ambulance capacity 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
Joseph Leonard Scott Cattle · 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
Joseph Leonard Scott Cattle contacted the Welsh Ambulance Service Trust at 00:44 in a call categorised as requiring an Amber 1 response, followed by two further calls. Paramedics did not attend until approximately 07:20, by which time he was deceased; concerns included the delay in allocating an ambulance, hospital handover delays affecting ambulance availability, and an apparent shortfall in funded ambulances.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover holding up ambulance resources
Wider context from the report “(2) Despite having their full complement of ambulance resources staffed and on shift many
of them were held up by delays in handover at hospitals ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays in allocating available ambulance resources to Amber 1 calls
Wider context from the report “(1) Welsh Ambulance Service Trust were unable to allocate an available ambulance
resource in an Amber 1 category call until over 6 hours from the time of the 999 call ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient funded ambulance capacity
Wider context from the report “(3) The number of funded ambulances appeared to be significantly short of what would
have been needed in the circumstances .
” 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 Direct each Local Health Board to develop a local Six Goals plan incorporating ambulance handover and patient-flow improvements.
Verbatim wording from the response “I have directed each LHB to develop a local ‘six goals’ programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. This programme plan forms a key part of LHBs’ broader Integrated Medium-Term Plans (IMTPs).” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor and scrutinise Local Health Board and ambulance-service performance against ambulance handover targets through regular assurance meetings and escalation arrangements.
Verbatim wording from the response “In practice, the Welsh Government monitors the performance of NHS Wales bodies in several different ways. In relation to the monitoring of ambulance patient handovers to emergency departments, a number of specific measures have been put in place in order to ensure the Welsh Government can assess how LHBs and WAST are performing.” Source location Response from Welsh Government
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 Issue guidance setting expectations and targets for timely ambulance handover, including required actions when handover exceeds 60 minutes.
Verbatim wording from the response “A Welsh Health Circular (“WHC”) was issued in 2016, setting out expectations of LHBs and partners to deliver timely ambulance patient handover through consistent delivery of a range of actions for both pre and post arrival such as: communication, alternative pathways, staffing levels, and booking in processes. It is the expectation of the Welsh Government that these actions are done consistently to meet handover targets.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Pathways of Care Delays Reporting Framework to provide regional data for targeting discharge interventions.
Verbatim wording from the response “To ensure we have accurate data on delayed discharges, the Pathways of Care Delays (PoCD) Reporting Framework has been implemented. This is a formal reporting mechanism that provides health and social care partners with a comprehensive and vital overview of their regional discharge delays so that relevant interventions and actions can be targeted more appropriately.” Source location Response from Welsh Government
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 Hold the NHS Joint Commissioning Committee chair accountable for effective emergency-ambulance commissioning and achievement of ministerial priorities.
Verbatim wording from the response “These commissioning arrangements were reviewed in 2022-23 as part of a wider independent review of national commissioning of NHS services in Wales. That review recommended establishing a new joint committee of LHBs to hold responsibility for commissioning of specialised services and emergency ambulance services among others. The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services.” Source location Response from Welsh Government
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 NHS Joint Commissioning Committee is responsible for determining the funding allocated to WAST for emergency ambulance services.
Verbatim wording from the response “These commissioning arrangements were reviewed in 2022-23 as part of a wider independent review of national commissioning of NHS services in Wales. That review recommended establishing a new joint committee of LHBs to hold responsibility for commissioning of specialised services and emergency ambulance services among others. The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services.” Source location Response from Welsh Government
Open published response
Concerns raised 17 Failure to require safety-training reference material View source Superficial and inadequate safety training View source Lack of independent periodic auditing and inspection View source Failure to impose and define effective restricted duties View source Failure to complete a timely Fatal Accident Inquiry Panel investigation View source Lack of robust training-compliance monitoring and responsibility clarity View source Delays and gaps in mandatory training completion View source Failure of central oversight of local safety execution View source Failure to ensure permit-holder competence and permit-scope clarity View source Failure to plan and provide appropriate first aid kits View source Failure to communicate death-related learning to coroners View source Lack of a culture of candour View source Failure to verify supplementary first-aid learning View source Insufficient safety-team resources and local reach View source Appointment of leaders without suitable competence or qualifications View source Insufficient Local Training Manager capacity View source Overly discretionary validation of inadequate training View source See 14 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
Benjamin David Leonard · 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
Benjamin David Leonard, aged 16, died after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the death.
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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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety-training reference material
Wider context from the report “13. Whilst reference material is available in the course, it is not mandatory reading and not required in order to complete the click through course.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Superficial and inadequate safety training
Wider context from the report “12. Safety training is predominantly done online. Having seen and forensically within the hearing, undertaken an exercise to complete the current Safety Module, I am concerned that the course is superficial at best and fundamentally basic . It can be completed in 12 minutes . It is unsurprising that the current pass rate is now correspondingly high. This causes concern as an introductory module needed to equip thousands of leaders with an understanding of how to complete a risk assessment in order to keep Scouts safe. It does not embed the fundamental principles of safety and safe scouting .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of independent periodic auditing and inspection
Wider context from the report “2. I am also concerned that, whilst the Charity Commission has regulatory oversight, there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities, hill walking and Nights Away permits. Further, The Scouts Association permit scheme for adventurous activities is exempt from regulation by the Health and Safety Executive (‘HSE’).
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to impose and define effective restricted duties
Wider context from the report “14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders ████████ were not subjected to “Restricted Duties” until 17.10.18 when Ben had died on 26.8.18 and in the time from Ben’s death, ████████ had taken part in a camp called “Deep Heat”. POR (Policy, Organisation and Rules) indicated the neutral act of suspension should have been imposed as a minimum for ████████. Once the restricted duties were issued, there was confusion as to whether these related to individuals or specific activities and at least one of the leaders continued in their Scouting obligations with no restrictions as it related to “Scouts” rather than “Explorer Scouts” and so the restrictions were ineffective .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a timely Fatal Accident Inquiry Panel investigation
Wider context from the report “4. As of 22.2.24, over 5 years since Ben’s death there is still no Fatal Accident Inquiry Panel Report in existence . Further still, even the prospective panel members for this investigation have not been identified . A document I have received entitled ‘BL Great Orme Learning and Actions Update’ dated 30.9.19 is inadequate when considering the root and branch type of review needed following a child fatality to identify and address issues of safety and safeguarding – particularly these having been identified as significant issues on the day of Ben’s death and despite this fact – no investigation followed -with The Scouts Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of robust training-compliance monitoring and responsibility clarity
Wider context from the report “20. I have heard evidence that The Scouts Association headquarters maintain that it is for the County and District as autonomous charities to monitor and audit training compliance. I am concerned that there are not robust systems of analysis, reporting and clarity as to the responsibilities of the County and District and what The Scouts Association require from the County and District in respect of:
i. Training compliance;
ii. Completion of induction training within 5 months;
iii. Completion of the full adult training scheme/ wood beads within 2 years;
iv. Appointment to roles – both pre provisional, provisional, and full appointment;
v. Granting of permits.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in mandatory training completion
Wider context from the report “29. These statistics lead to the clear conclusion that there were widespread and significant gaps in training being completed in a timely manner , with concerns surrounding the training provision in the Stockport District.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure of central oversight of local safety execution
Wider context from the report “36. The Scouts Association is distant from its membership through its federated branches of 8000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level . Training and POR are generated centrally, yet The Scouts Association defer accountability for safeguarding and safety to the individual charities .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure permit-holder competence and permit-scope clarity
Wider context from the report “38. The example of ████████ having been granted his Nights Away permit simply by providing a list of camps he had been on, demonstrates that there was no robust system in place to ensure that a permit holder responsible for children’s safety was suitably qualified . There is no evidence he had the necessary skills and competencies to be granted such a permit. There was also a lack of clarity on where permits would be required for activities outside of the ordinary Scouts meeting place.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and provide appropriate first aid kits
Wider context from the report “32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required . None of the leaders had a first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate death-related learning to coroners
Wider context from the report “11. I therefore have concerns that not all matters regarding deaths connected with the Scouting Movement and Association are being communicated , even by provision of draft report and recommendations, to His Majesty’s Coroners of England and Wales to inform PFD issues and a Coroner’s PFD reporting duties.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within The Scouts Association (‘TSA’) and the impact that this has on safety and safeguarding.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to verify supplementary first-aid learning
Wider context from the report “34. There was a system in place whereby if a learner had a first aid at work certificate, they could self-certify that they had undertaken further learning, for Child CPR, hypothermia and meningitis to comply with Module 10 First Response. There were no checks to ensure that this further learning had been done, nor was it assessed .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety-team resources and local reach
Wider context from the report “37. The centralised safeguarding team and safety team are not on par with each other in terms of resources and reach to local level . Safety is not prioritised in the same way as safeguarding has been . Safeguarding is reacted to more quickly than safety by The Scouts Association.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Appointment of leaders without suitable competence or qualifications
Wider context from the report “19. This gives rise to a concern that there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety and safeguarding.
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient Local Training Manager capacity
Wider context from the report “31. I am concerned by evidence at the inquest that, presently, Stockport only has 6 Local Training Managers in post where 9 are required . The remaining 3 are “awaiting appointment” .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Overly discretionary validation of inadequate training
Wider context from the report “23. For Local Training Managers (‘LTM’) a process for validation exists whereby a training adviser interprets the Training Advisers Guide and has a broad scope within which they can validate a learner’s training . This creates a risk of the approval of superficial and inadequate learning .
” Open source report
Concerns raised 12 Unavailability of out-of-hours emergency endoscopy View source Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose View source Lack of clarity about when to call the Emergency Treatment Team View source Insufficient Emergency Department space for patient demand View source Insufficient doctors and nurses for Emergency Department patient demand View source Failure to adequately share investigation learning with practitioners View source Failure to sufficiently identify and action issues from investigation findings View source Failure to record triage of ambulance arrivals at the Emergency Department View source Failure to maintain consistent investigation report content View source Failure to admit ambulance patients promptly and return ambulances to active duty View source Ineffective triage of ambulance arrivals at the Emergency Department View source Lack of clarity about when to engage the Major Haemorrhage Pathway View source See 9 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
Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours emergency endoscopy
Wider context from the report “1. An out of hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be 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 Government; that does not assign responsibility.
PFD Monitor interpretation Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
Wider context from the report “6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call the Emergency Treatment Team
Wider context from the report “4. There is not a clear understanding of when the Emergency Treatment Team should be called ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient Emergency Department space for patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctors and nurses for Emergency Department patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately share investigation learning with practitioners
Wider context from the report “7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently identify and action issues from investigation findings
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to record triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain consistent investigation report content
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to admit ambulance patients promptly and return ambulances to active duty
Wider context from the report “9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff , due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty .
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Ineffective triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” 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 Government; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to engage the Major Haemorrhage Pathway
Wider context from the report “5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged ;
” 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 an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.
Verbatim wording from the response “In view of my concern, all health board chief executives were directed to prioritise three actions for delivery over the winter months as part of a new NHS Wales ambulance patient handover improvement plan implemented from the festive period 2023/2024. As part of their local plan, the Betsi Cadwaladr University Health Board priority actions include:” Source location Response from Welsh Government
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 Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
Verbatim wording from the response “To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations of health boards and NHS trusts through an annual NHS planning framework. Organisations are expected to produce integrated medium-term plans annually, that respond to the priorities set in the NHS planning framework. The planning framework clearly sets out my expectation that health boards prioritise plans to improve timeliness of ambulance patient handovers to free up ambulance clinicians to respond to patients in the community. Given the relationship between both timely patient discharge and ambulance patient handover, I have also set a priority for improvement in patient flow.” Source location Response from Welsh Government
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 Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.
Verbatim wording from the response “In addition, I directed the Chief Ambulance Services Commissioner to monitor delivery of plans intended to secure improvements through Emergency Ambulance Services Committee governance mechanisms. The Committee, made up of the seven chief executives of health boards, agreed to work towards eradicating all handover delays over four hours in length by the end of 2024/2025.” Source location Response from Welsh Government
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 Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.
Verbatim wording from the response “• I hold health board chairs to account for delivery and have incorporated ambulance patient handover improvement as a key objective for all chairs for 2023/2024. I consistently seek assurance from chairs as a collective on their organisations’ commitment to making improvements through regular national meetings.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide over £500,000 to improve Betsi Cadwaladr emergency-department facilities and waiting-room experiences.
Verbatim wording from the response “Turning to strategic plans to support improvement in quality of care in emergency departments. I continue to support improvements in emergency departments through a range of measures and this year will publish a Quality Statement for care within the emergency departments, setting out my expectations for the service. To deliver this, we are bringing the voices of our clinical leaders together through the newly established Strategic Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters most to people who use the service. I made over £500,000 of additional funding available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments which will enhance both patient and staff experiences in waiting rooms.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £50 million in additional funding to support urgent and emergency care improvement.
Verbatim wording from the response “To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:” Source location Response from Welsh Government
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 Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
Verbatim wording from the response “To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:” Source location Response from Welsh Government
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.
Verbatim wording from the response “• There are established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Assurance is sought and challenge provided on a regular basis regarding ambulance patient handover performance, through ‘integrated quality, planning and delivery (IQPD)’ meetings between Welsh Government, the NHS Executive and NHS organisations.” Source location Response from Welsh Government
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 Fund expanded same-day emergency care capacity across north Wales district general hospitals.
Verbatim wording from the response “• We have funded extensions in capacity for same day emergency care services which are treating and discharging hundreds of patients per month across the three district general hospitals in north Wales, freeing up precious bed capacity;” Source location Response from Welsh Government
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 Responsibility for delivering health services, including ambulance handover improvements, rests with the health board rather than Welsh Ministers.
Verbatim wording from the response “My response will largely focus upon the ninth matter of concern in the report, regarding the timeliness of ambulance patient handover, and the health board will reply on matters of concerns 1 – 8. My officials have worked with the health board to ensure that our responses are co-ordinated and consistent. It is important to ensure lines of accountability are clear given that responsibility for delivery of services falls with the health board. The role of the Welsh Ministers is to set the strategic direction for health boards and NHS trusts and to hold them to account for delivery of policy.” Source location Response from Welsh Government
Open published response
Concerns raised 1 Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery 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
Catherine Lisa 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
Catherine Lisa Jones died at Wrexham Maelor Hospital on 10 November 2016 from widespread metastatic ovarian cancer contributed to by pseudomembranous colitis. The report describes concerns that a biopsy had been wrongly classified as benign, that a lesion was not identified during subsequent surgery or on a scan, and that surgery conducted through pooled lists was not supported by a documented, approved system of work, potentially resulting in a lack of cohesive care and treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery
Wider context from the report “It was indicated that for many departments within the health board, surgery was conducted on the basis of “pooled lists” and although evidence was given that the common practice of one of the surgeons was to ensure that they had some form of communication with the patient’s consultant prior to surgery (by phone and/or email), there was no evidence that this practice was part of an approved system of work which was documented within the health board’s protocols .
In the absence of this being a part of an adopted practice and procedure guidance , I am concerned that there may be a lack of cohesive care and treatment for patients undergoing surgery and that future death may occur as a result.
” Open source report
15 Nov 2023 Lynda BLACKMORE · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lynda BLACKMORE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital
Wider context from the report “My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital . As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016 .
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
” Open source report
25 Oct 2023 Bronwen Grace MORGAN (BM) · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites 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
Bronwen Grace MORGAN (BM) · 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
Bronwen Morgan, who was under the care of local mental health services, travelled to a hotel on 27 August 2020 and was later found there by emergency services. She was conveyed to hospital, where she died from the toxic consequences of a substance after resuscitation attempts failed. The principal concern was that an online forum and potentially similar sites enabled vulnerable people to discuss, obtain information about, and acquire means for self-harm or suicide.
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 Government; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites
Wider context from the report “The evidence revealed that as from at least February 2020, BM had registered with, & was engaging in discussion forums ████████ This website was mentioned in an earlier PFD Report dated 3.12.19 (copy annexed).
The engagement that BM had with the website encompassed her discussing & seeking advice from fellow users in respect of, methods of self-harm/suicide including the purchasing & use of the substance ████████. This was the substance used by BM which led to her death.
The concern here is that this site & potentially similar self-harm & suicide “facilitating or promoting” sites are accessible/available to those, such as BM who are vulnerable, due to their diagnosed, or otherwise mental illness & provided with an outlet/forum to source & acquire information that potentially equips them with the knowledge & means to either complete suicide, or place them in grave/greater danger of doing so.
I believe that consideration ought to be given to the impact such access/availability has upon those vulnerable individuals researching/contemplating acts of self-harm & whether, & what action(s) may be taken to remove/limit/mitigate/educate such access/availability.
” Open source report
20 Jan 2023 Dorothy Anne Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need View source Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines View source Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness View source Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dorothy Anne Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Allocation of Amber 1 ambulance resources chronologically without further consideration of clinical need
Wider context from the report “2. The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Ad hoc clinician intervention to expedite ambulance responses without local policy or guidelines
Wider context from the report “3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited . However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
Wider context from the report “4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed , under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe
Wider context from the report “1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent , where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients .
” Open source report
31 Jan 2022 Eirlys Wynne Roberts · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1 Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eirlys Wynne Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Eirlys Wynne Roberts, aged 93, suffered a fall at a residential home, fractured her neck of femur, underwent surgery, and died a short time later. The report raised concern about the shortage and lack of timely availability of residential, EMI residential, and EMI nursing placements for elderly people whose cognitive and physical care needs change, potentially putting them at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Welsh Government; that does not assign responsibility.
PFD Monitor interpretation Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs
Wider context from the report “There was evidence heard during the Inquest that when a residential home was required given the deceased’s needs that the homes in Gwynedd were all full and that consideration would need to be given to placements outside of the area. Eventually a placement was identified. When further deterioration was noted whereby the deceased required a higher level of care by way of an EMI residential placement one was not immediately available. The deceased therefore remained at the residential home. When her needs further increased whereby an EMI nursing placement was required, again there was no availability. I am concerned by the lack of available placements for the elderly as and when their cognitive and physical needs change thereby putting them at risk. The evidence was that there is a shortage of placements and it is concerning that specific needs of the elderly cannot always be met either at all or in a timely manner.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run the WeCare.Wales national recruitment campaign to support social care workforce recruitment.
Verbatim wording from the response “Workforce
Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen regional partnership arrangements covering governance, scrutiny, planning, performance, engagement, integrated delivery and social care market rebalancing.
Verbatim wording from the response “These included the development of a strategic National Framework for care and support, which will set standards for commissioning practice, reduce complexity, and focus on quality and outcomes. The implementation of this Framework will be overseen by a National Office within Welsh Government. In addition, we are committed to strengthening regional partnership arrangements to support stronger partnership working and deliver for local populations, with a focus on governance and scrutiny, planning and performance, engagement and voice, integrated service delivery, and rebalancing the social care market.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Announce introduction of the Real Living Wage for social care workers.
Verbatim wording from the response “In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national care and support framework setting commissioning standards, with implementation overseen by a National Office.
Verbatim wording from the response “In January 2021 Welsh Government issued the Rebalancing Care and Support White Paper, proposing legislative and other changes we believe are essential to securing the vision set out in the Act.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to regional partnership, health board and social services leaders asking them to review older people’s residential care provision and assess sufficiency in forthcoming reports.
Verbatim wording from the response “The Minister for Health and Social Services will write to the Chairs of the seven Regional Partnership Boards in Wales, the Chief Executives of the Health Boards and Directors of Social Services to ask them to review their current provision for older peoples residential care, including EMI beds and to ensure that their imminent Population Needs Assessments and Market Stability Reports robustly explore the sufficiency of provision. Any action to improve the commissioning and sufficiency of such provision should then be set out in their forthcoming Area Plans.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase funding for targeted recruitment initiatives and support people considering social care employment.
Verbatim wording from the response “Workforce
Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional funding to strengthen the social care sector and support pandemic-related costs.
Verbatim wording from the response “Financial support
During the Covid pandemic the Welsh Government has made significant resources available to local authorities and health boards, to ensure that social care providers can meet the additional costs arising because of the pandemic. The recently published Welsh Government budget for 2022-25 provides an additional £180m to local authorities directly to strengthen the social care sector, with further reform and capital funding also being allocated.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the Social Care Fair Work Forum to consider further measures to attract people into social care.
Verbatim wording from the response “In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities and health boards are responsible for planning and commissioning sufficient residential and nursing care provision.
Verbatim wording from the response “Integrated planning and commissioning
Welsh Government has put in place mechanisms to enable Local Authorities and the NHS to better meet changing population needs. They have clear responsibilities to plan and commission care and support services that meet the needs of their local populations, including the commissioning of residential and nursing care for those who need it. Under the Act, local authorities and health boards are required to work together, through the Regional Partnership Boards, to produce five yearly Population Needs Assessments and Market Stability Reports. These must be based upon assessments of local population needs, the range and level of services required to meet those needs, sufficiency of provision, and the stability and sustainability of the market for regulated services such as domiciliary and residential care.” Source location 2022-0034-Response-from-Welsh-Government_Published
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations