Concerns raised 2 Inadequate speed control for traffic approaching the junction View source Failure to maintain adequate visibility from the junction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Jane 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
Emma Jane Hill was a pillion passenger on a motorcycle that collided with a motor vehicle at a junction on the A534, and she sustained fatal injuries. Concerns were raised that obstructed visibility, vehicles travelling at speed, the road layout and previous collisions in the area created an ongoing risk of further collisions and loss of life.
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 Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate speed control for traffic approaching the junction
Wider context from the report “Following discussions with the Roads Traffic Policing Unit of North Wales Police, I am concerned that although at this location the A534 is a comparatively straight stretch road, the visibility from the junction when turning right out of the village in the direction of Wrexham may on occasions be obstructed by signage and/or by vehicles which are slowing to turn into the village.
Furthermore as this straight stretch of road is subject to a national speed limit following a 40 mph zone, traffic may be accelerating or travelling at speed, thus creating risk both for persons exiting the junction and traffic which is continuing along the main road .
It is also my understanding that there have been previous collisions in this vicinity in the past.
Unless action is taken to improve visibility, reduce the speed of traffic or to alter the road layout, then there is an ongoing risk that further collisions will occur and that lives may be lost as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate visibility from the junction
Wider context from the report “Following discussions with the Roads Traffic Policing Unit of North Wales Police, I am concerned that although at this location the A534 is a comparatively straight stretch road, the visibility from the junction when turning right out of the village in the direction of Wrexham may on occasions be obstructed by signage and/or by vehicles which are slowing to turn into the village .
Furthermore as this straight stretch of road is subject to a national speed limit following a 40 mph zone, traffic may be accelerating or travelling at speed, thus creating risk both for persons exiting the junction and traffic which is continuing along the main road.
It is also my understanding that there have been previous collisions in this vicinity in the past.
Unless action is taken to improve visibility , reduce the speed of traffic or to alter the road layout, then there is an ongoing risk that further collisions will occur and that lives may be lost as a result.
” 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 Commit in principle to reducing the road speed limit through a joint Traffic Regulation Order consultation process.
Verbatim wording from the response “I can confirm that our Network & Asset Team Leader has liaised with colleagues from Cheshire West & Chester Council in relation to the speed limit reduction. Whilst this would be subject to a formal Traffic Regulation Order (TRO) consultation process, both Local Authorities have given a principle commitment to reducing the speed limit on this road and doing so in partnership given the road crosses the border.” Source location Response from Wrexham County Borough Council
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 the junction through the Road Safety Officer to identify visibility and other safety improvements.
Verbatim wording from the response “Additionally, the location has been assessed by our Road Safety Officer. It has been determined that the junction would benefit from some minor alterations and we have already raised the sign on the junction to improve visibility. The other improvements can be achieved with amendments to the road markings. We have been notified by North Wales Police that a reconstruction of the collision is planned for the week commencing 2 June 2025 and therefore it would be prudent to await the outcome of that ahead of finalising our proposals. The implementation of the road marking alterations will be commissioned when the speed limit TRO consultation outcome has been determined.” Source location Response from Wrexham County Borough Council
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 Liaise with Cheshire West and Chester Council on reducing the cross-border road speed limit.
Verbatim wording from the response “I can confirm that our Network & Asset Team Leader has liaised with colleagues from Cheshire West & Chester Council in relation to the speed limit reduction. Whilst this would be subject to a formal Traffic Regulation Order (TRO) consultation process, both Local Authorities have given a principle commitment to reducing the speed limit on this road and doing so in partnership given the road crosses the border.” Source location Response from Wrexham County Borough Council
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 Raise the junction sign to improve visibility.
Verbatim wording from the response “Additionally, the location has been assessed by our Road Safety Officer. It has been determined that the junction would benefit from some minor alterations and we have already raised the sign on the junction to improve visibility. The other improvements can be achieved with amendments to the road markings. We have been notified by North Wales Police that a reconstruction of the collision is planned for the week commencing 2 June 2025 and therefore it would be prudent to await the outcome of that ahead of finalising our proposals. The implementation of the road marking alterations will be commissioned when the speed limit TRO consultation outcome has been determined.” Source location Response from Wrexham County Borough Council
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 Finalising junction improvement proposals is deferred pending the planned collision reconstruction outcome.
Verbatim wording from the response “Additionally, the location has been assessed by our Road Safety Officer. It has been determined that the junction would benefit from some minor alterations and we have already raised the sign on the junction to improve visibility. The other improvements can be achieved with amendments to the road markings. We have been notified by North Wales Police that a reconstruction of the collision is planned for the week commencing 2 June 2025 and therefore it would be prudent to await the outcome of that ahead of finalising our proposals. The implementation of the road marking alterations will be commissioned when the speed limit TRO consultation outcome has been determined.” Source location Response from Wrexham County Borough Council
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 Road-marking alterations will not be commissioned until the speed-limit Traffic Regulation Order consultation outcome is determined.
Verbatim wording from the response “Additionally, the location has been assessed by our Road Safety Officer. It has been determined that the junction would benefit from some minor alterations and we have already raised the sign on the junction to improve visibility. The other improvements can be achieved with amendments to the road markings. We have been notified by North Wales Police that a reconstruction of the collision is planned for the week commencing 2 June 2025 and therefore it would be prudent to await the outcome of that ahead of finalising our proposals. The implementation of the road marking alterations will be commissioned when the speed limit TRO consultation outcome has been determined.” Source location Response from Wrexham County Borough Council
Open published response
10 Jul 2023 Mary Elizabeth Jones · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 3 Delays in ambulance response and arrival View source Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies View source Inability to offload patients from ambulances into Emergency Departments in a timely manner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mary Elizabeth Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response and arrival
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inability to offload patients from ambulances into Emergency Departments in a timely manner
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales .
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” Open source report
Concerns raised 3 Delays in ambulance attendance View source Inadequate cohesive forward planning for short-term pressures and longer-term solutions View source Lack of adequate social care placements or community care for patients medically fit for hospital discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emlyn Victor Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable .
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times , was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better .
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate cohesive forward planning for short-term pressures and longer-term solutions
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community ).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” Open source report
Concerns raised 4 Delays in ambulance handover at hospitals View source Failure to maintain timely ambulance availability and arrival for patients View source Insufficient social care capacity causing hospital patient-flow and ambulance offload delays View source Lack of meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Frickel · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals ).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely ambulance availability and arrival for patients
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available .
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report
Concerns raised 3 Delays in ambulances arriving to patients View source Delays in ambulance handover at hospitals View source Inadequate social care placements or community care for patients medically fit for discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leonard Charles Harmsworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulances arriving to patients
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals .
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate social care placements or community care for patients medically fit for discharge
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community ).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report
Concerns raised 1 Obstructed visibility for vehicles joining the A525 from Green Lane View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Howard Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Howard Williams died at the scene after his motorcycle collided with a motor car turning onto the A525 from Green Lane. The inquest evidence indicated that a hedge obstructed the view for vehicles joining the A525, creating an ongoing risk of further collisions and loss of life unless visibility or the road layout is improved.
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 Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Obstructed visibility for vehicles joining the A525 from Green Lane
Wider context from the report “The evidence at inquest, supported by a site visit by me to the scene, indicated that the view for vehicles joining the A525 at this location from Green Lane is obstructed as to traffic approaching from the Wrexham direction as a result of the hedge which abuts the highway at this point .
Unless action is taken to improve visibility or to alter the road layout, then there is an ongoing risk that further collisions will occur and that lives may be lost as a result .
” 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 Make a Traffic Regulation Order restricting Green Lane to one-way traffic from the A525 direction.
Verbatim wording from the response “It is the intention of the Authority to make a Traffic Regulation Order on Green Lane to make the road one way from the direction of the A525. This will not allow vehicles to exit Green Lane onto the A525, which will avoid vehicles entering the A525 where there is limited visibility.” Source location Response from Wrexham County Borough Council
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 Cut the hedge bordering the A525 and Hollybush House to improve visibility.
Verbatim wording from the response “I would confirm that we will be cutting the hedge which borders the A525 and the premises of Hollybush House, at this present time the house is in the process of being sold, but we will be speaking to the new owner when they take up occupancy regarding the maintenance of the hedge.” Source location Response from Wrexham County Borough Council
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 Speak with Hollybush House’s new occupier about maintaining the hedge bordering the A525.
Verbatim wording from the response “I would confirm that we will be cutting the hedge which borders the A525 and the premises of Hollybush House, at this present time the house is in the process of being sold, but we will be speaking to the new owner when they take up occupancy regarding the maintenance of the hedge.” Source location Response from Wrexham County Borough Council
Open published response
Concerns raised 2 Failure to make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm View source Inadequate arrangements to protect people under mental health care after indications of an immediate risk of harm 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
Hannah Elizabeth Browning · 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
Hannah Elizabeth Browning, who was receiving treatment for mental health issues and had a history of self-harm and suicidal thoughts, expressed an intention to end her life on 10 October 2018. She subsequently placed a ligature around her neck and sustained a hypoxic brain injury, dying at Wrexham Maelor Hospital on 12 October 2018. The principal concern was that inadequate arrangements and insufficient efforts were made by Mental Health Services to protect her and contact her after she indicated an immediate risk of harm.
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 Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm
Wider context from the report “That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis .
Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements to protect people under mental health care after indications of an immediate risk of harm
Wider context from the report “That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis.
Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves.
” Open source report
Concerns raised 3 Lack of staff understanding and empathy regarding care and service delivery issues View source Inadequate CMHT staff training in risk assessment View source Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment 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
Daniel Watson · 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
Daniel Watson was found hanged at his home on 5 June 2017 and was verified dead from hanging. The report identified care and service delivery problems, missed opportunities to improve his mental health, and concerns about staff understanding of risk assessment and escalation towards formal psychiatric assessment.
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 Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding and empathy regarding care and service delivery issues
Wider context from the report “1. The Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and service delivery problems and contributory factors in relation to the care and treatment of the Deceased which cumulatively represented missed opportunities to improve his mental health and the evidence given at the inquest by the social worker and community psychiatric nurse demonstrated a complete lack of understanding and empathy in relation to these issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate CMHT staff training in risk assessment
Wider context from the report “2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment
Wider context from the report “2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment .
” Open source report
Concerns raised 4 Delays in emergency department patient handover View source Failure to maintain adequate emergency department staffing View source Insufficient hospital bed capacity for admissions View source Failure of hospital patient flow and delayed transfer of care processes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lilly Baxandall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency department patient handover
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls" .
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays /bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate emergency department staffing
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients" .
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital bed capacity for admissions
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions ”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrexham County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care .
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment ”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations