Shirley Ann Hughes · Prevention of Future Deaths report

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Issued 28 Oct 2024•North Wales (East and Central)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

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 raised1

  1. Failure of the MPDS system to remain fit for purpose for response prioritisation
    Part of recurring concern: Unreliable Medical Priority Dispatch System emergency assessment and advice pathwaysPart of recurring concern: Unreliable ambulance response-time standards and prioritisation

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Welsh Ambulance Services NHS Trust

    Use the deployed Emergency Communication Nurse System and Call Priority Streaming System to support the Trust’s clinical and call-prioritisation strategy.

  2. Welsh Ambulance Services NHS Trust

    Work with commissioners and system partners to identify and develop appropriate referral pathways for Trust clinicians.

  3. Welsh Ambulance Services NHS Trust

    Adopt personalised care planning with clinical oversight throughout each patient episode until resolution.

  4. Welsh Ambulance Services NHS Trust

    Create additional face-to-face response options to support safe treatment at home and avoid unnecessary emergency-department conveyance.

  5. Welsh Ambulance Services NHS Trust

    Continue evolving the Clinical Services Model to improve care pathways and resource use.

  6. Welsh Ambulance Services NHS Trust

    Monitor the impact of service developments and work with commissioners and partners on further development and collaboration.

  7. Welsh Ambulance Services NHS Trust

    Undertake targeted engagement with key stakeholders, including coronial services, to support emerging plans.

  8. Welsh Ambulance Services NHS Trust

    Embed new clinical roles in control rooms to triage 999 calls earlier and support better care decisions.

  9. Welsh Ambulance Services NHS Trust

    Continue reconfiguring resource allocation and report regularly to the Trust Board on measures to mitigate patient harm.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Welsh Ambulance Services NHS Trust

    Developing an alternative call-prioritisation system would require significant in-house work beyond the Trust’s capacity and capability.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. Welsh Ambulance Services NHS Trust

    The Trust does not consider itself the primary authority with power to take further action under the relevant statutory reporting provisions.

    Outside remitThe respondent said that this matter was outside its role or authority.
  3. Welsh Ambulance Services NHS Trust

    MPDS remains the best available call-prioritisation product for the Trust, supported by linked ECNS and CPSS systems.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. Welsh Ambulance Services NHS Trust

    The 2015 reference concerned a Clinical Response Model trial; the 20-minute Amber 1 target was internal and ceased in 2017.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  5. Welsh Ambulance Services NHS Trust

    No additional actions are proposed because existing plans are already being enacted to manage identified risks and resource pressures.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 of the MPDS system to remain fit for purpose for response prioritisation

Wider context from the report

“For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however on every occasion when evidence is presented at inquests, I am reminded that calls are prioritised using the Medical Priority Dispatch System (MPDS) by which a code is generated and that this is then matched to a response priority to provide an indication as to the most appropriate resource to respond. At the inquest of Mrs Hughes, I was advised that MPDS was introduced in 2015 and at that time it was envisaged that an amber 1 priority call would be responded to in 20 minutes, however it was clearly the case that the multifactorial issues which prevail today were not envisaged at that time and that as a consequence this raises questions as to whether the MPDS system remains fit for purposes. As a result of this evidence, I am concerned that lives are being put at risk. ”

Is this part of a recurring concern?

Yes — Unreliable Medical Priority Dispatch System emergency assessment and advice pathways; Unreliable ambulance response-time standards and prioritisation.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Use the deployed Emergency Communication Nurse System and Call Priority Streaming System to support the Trust’s clinical and call-prioritisation strategy.

Verbatim wording from the response

“In the absence of NHS Pathways or MPDS, it would require significant inhouse development to produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also deployed Emergency Communication Nurse System (ECNS) and Call Priority Streaming System (CPSS), both of which support our strategic direction. These are from the same provider as MPDS. There are a number of advantages presenting themselves, which is the potential synergies between MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 and 111 contacts).”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 1 November 2024

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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 commissioners and system partners to identify and develop appropriate referral pathways for Trust clinicians.

Verbatim wording from the response

“○ Care Planning: We will adopt a personalised care planning approach for all patients, providing robust clinical oversight of the patient throughout their episode of care until their needs are resolved and case closed with the ambulance service. ○ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. ○ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care pathways for Trust clinicians to safely and appropriately refer patients to meet their care needs.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

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

Adopt personalised care planning with clinical oversight throughout each patient episode until resolution.

Verbatim wording from the response

“○ Care Planning: We will adopt a personalised care planning approach for all patients, providing robust clinical oversight of the patient throughout their episode of care until their needs are resolved and case closed with the ambulance service. ○ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. ○ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care pathways for Trust clinicians to safely and appropriately refer patients to meet their care needs.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

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

Create additional face-to-face response options to support safe treatment at home and avoid unnecessary emergency-department conveyance.

Verbatim wording from the response

“○ Care Planning: We will adopt a personalised care planning approach for all patients, providing robust clinical oversight of the patient throughout their episode of care until their needs are resolved and case closed with the ambulance service. ○ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. ○ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care pathways for Trust clinicians to safely and appropriately refer patients to meet their care needs.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

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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 evolving the Clinical Services Model to improve care pathways and resource use.

Verbatim wording from the response

“In addition to the Governmental task and finish group referenced above, and aligned to our 2024-27 IMTP, the Trust has commenced work to evolve its Clinical Services Model. We have provided an overview of our current position and planned incremental changes under the headings below.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 3 · response
Published 1 November 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Monitor the impact of service developments and work with commissioners and partners on further development and collaboration.

Verbatim wording from the response

“▪ We will be monitoring the impact of these developments and working with commissioners and partners to work through opportunities for further development and collaboration.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Undertake targeted engagement with key stakeholders, including coronial services, to support emerging plans.

Verbatim wording from the response

“▪ We will be undertaking more targeted engagement with key stakeholders, including coronial services, to support our emerging plans in the near future.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

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

Embed new clinical roles in control rooms to triage 999 calls earlier and support better care decisions.

Verbatim wording from the response

“▪ As part of our plans for winter we are embedding new clinical roles in our control rooms to proactively triage 999 calls earlier in the call cycle. By using clinical expertise, it enables more effective clinical decisions regarding the best care to meet the patient’s needs.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 4 · response
Published 1 November 2024

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

Continue reconfiguring resource allocation and report regularly to the Trust Board on measures to mitigate patient harm.

Verbatim wording from the response

“We continue to work tirelessly at internal mechanisms to reconfigure and improve resource allocation, regularly reporting to our Trust Board on the steps taken to mitigate patient harm. However, we recognise that we are not an organisation with a full solution in the broader context. I am therefore extending an offer to meet with you to discuss our response in more detail, and to provide you with any further assurances you may require regarding our commitment to continual improvement to proactively prevent harm and future deaths.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 5 · response
Published 1 November 2024

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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

Developing an alternative call-prioritisation system would require significant in-house work beyond the Trust’s capacity and capability.

Verbatim wording from the response

“In the absence of NHS Pathways or MPDS, it would require significant inhouse development to produce a call prioritisation system and the Trust does not have capacity or capability to pursue this. During the pandemic, MPDS protocols were more flexible to our needs, compared to NHS Pathways, and as such the Trust feels it remains the best product for the Trust to utilise. The Trust has also deployed Emergency Communication Nurse System (ECNS) and Call Priority Streaming System (CPSS), both of which support our strategic direction. These are from the same provider as MPDS. There are a number of advantages presenting themselves, which is the potential synergies between MPDS (999 system), CPSS (111 system) and ECNS (clinical assessment system now used for both 999 and 111 contacts).”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 1 November 2024

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

The Trust does not consider itself the primary authority with power to take further action under the relevant statutory reporting provisions.

Verbatim wording from the response

“While the Trust fully supports the need to issue a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, we do not believe that we are the primary authority with the “power to take such action”. Therefore, I respectfully request your consideration as to any further actions you feel the Trust could take, over and above those that we have already shared with you. Equally, I would genuinely welcome any suggestion you may have regarding actions we might take or seek to take with our partners.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 5 · response
Published 1 November 2024

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

MPDS remains the best available call-prioritisation product for the Trust, supported by linked ECNS and CPSS systems.

Verbatim wording from the response

“To the Trust’s knowledge, MPDS and NHS Pathways are the only available products, worldwide. NHS Pathways is only used in England. In comparison to MPDS, NHS Pathways has a very small group of users, and the number of patients triaged using this tool versus MPDS is very small.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 1 November 2024

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

The 2015 reference concerned a Clinical Response Model trial; the 20-minute Amber 1 target was internal and ceased in 2017.

Verbatim wording from the response

“Your reference to 2015, we believe refers to the trial of a new Clinical Response Model (CRM) which commenced in October 2015. The CRM guides the way in which the Trust utilises its resources. An initial trial was undertaken for 12 months and extended by a further 6 months. In February 2017, the CRM was approved by Welsh Government and has remained in place since that time.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 1 November 2024

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

No additional actions are proposed because existing plans are already being enacted to manage identified risks and resource pressures.

Verbatim wording from the response

“The Trust does not propose to take any additional, or new, actions specifically in relation to this Preventing Future Deaths report because of existing plans already being enacted. Whilst we recognise that this may appear insensitive given the loss Mrs Hughes’ family have experienced and in light of the risks you raise with us, we hope to provide assurance that the Trust already recognised the risks and pressures within Urgent and Emergency care pathways and is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from its commissioners through its commissioning body, the JCC, Welsh Government, the wider NHS and Local Government to ensure appropriate clinical risk management across the urgent and emergency care pathway to release resources with the Trust.”

Source location

Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 1 November 2024

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