PFD report

Michael Jonathan Davies · Prevention of Future Deaths report

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Issued 25 Apr 2019•Carmarthenshire and Pembrokeshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Delays in emergency response for patients with chest pains and related conditions
    Part of recurring concern: Delays in ambulance attendance
  2. Failure to categorise conscious, breathing patients with chest pains and related conditions as Category Red
    Part of recurring concern: Unreliable ambulance call triage and re-triage
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The response model appropriately assigns red priority only to chest-pain calls involving unconsciousness and absent breathing.

    Stated by Welsh Ambulance Services NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in emergency response for patients with chest pains and related conditions

Wider context from the report

“1. During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed in an Amber 1 categorisation whenever the patient is conscious and breathing. The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response. 2. The effect of removing chest pains and related conditions from Category Red is the response time, previously 8 minutes, is now up to 4 hours and often patients are advised to make their own way to hospital. 3. This puts patients’ lives at risk and in this inquest may have contributed to the death of Mr Davies. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to categorise conscious, breathing patients with chest pains and related conditions as Category Red

Wider context from the report

“1. During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed in an Amber 1 categorisation whenever the patient is conscious and breathing. The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response. 2. The effect of removing chest pains and related conditions from Category Red is the response time, previously 8 minutes, is now up to 4 hours and often patients are advised to make their own way to hospital. 3. This puts patients’ lives at risk and in this inquest may have contributed to the death of Mr Davies. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance call triage and re-triage.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The response model appropriately assigns red priority only to chest-pain calls involving unconsciousness and absent breathing.

Verbatim wording from the response

“As you explored during the inquest, each ambulance service has a response model that supports the categorisation given to each call (irrespective of which prioritisation system is used). That response model and the decisions made will reflect the demographics of the population and the geography being served by that individual ambulance service. I notice that you have relied on evidence informing your view and subsequently raising the noted concerns that England (or parts thereof) have some chest pains as a red category of call, requiring an 8 minute response. I would respectfully draw to your attention to the fact that England operates a national system of response prioritisation (following the introduction of the Ambulance Response Program (ARP).”

Source location

2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 2 · response
Published 14 June 2019

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amber 1 calls do not have planned four-hour delays, and self-transport advice is given only when clinically appropriate and safe.

Verbatim wording from the response

“With regard to point 2 of the Regulation 28 Report, I would like to take the opportunity to explain that Amber 1 calls do not attract a planned response of up to four hours within the clinical response model, nor is it correct to say that patients are often advised to make their own way to hospital. It would be right to say however that around 10% of all patients who dial 999 are offered advice by a senior clinician over the telephone which may include self-care advice or instructions to make their own way to a healthcare facility. This is only the case where it is clinically appropriate and safe to do so and supports the provision of sufficient emergency ambulance capacity being available to respond to those patients who do genuinely require such.”

Source location

2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 2 · response
Published 14 June 2019

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

Immediate vehicle allocation is not always possible when demand exceeds available ambulance supply.

Verbatim wording from the response

“Whilst the Trust in its letter to ████████ and in the oral evidence provided at the inquest, acknowledges that there was a delay in an ambulance being allocated to Mr Michael Davies on 7 February 2018, this was an unavoidable delay. This is because at 11.25 hours when the call was received, and allocated the Amber 1 categorisation, there were no vehicles available to the Trust to send to Mr Michael Davies. This resulted in the open microphone call being made to all ambulances in the vicinity at 11.31 hours.”

Source location

2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 3 · response
Published 14 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Revise call-taker scripts used in clinical contact centres to provide demand-management advice for callers.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Revise call-taker scripts used in clinical contact centres to provide demand-management advice for callers.

Verbatim wording from the response

“During the inquest, specifically the evidence provided by ████████, you were informed that since February 2018 changes have been made to the scripts used by the call takers within our clinical contact centres. ████████ did advise that she was unable to answer your questions in relation to what callers were now told as she did not have that information available to her.”

Source location

2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 2 · response
Published 14 June 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026