Report evidence summary
× 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 hospital handover
Wider context from the report “The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
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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 ambulance response to life-threatening emergencies
Wider context from the report “The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
” Is this part of a recurring concern? Yes — Delays in ambulance attendance .
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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 WAST to develop a virtual ward model.
Verbatim wording from the response “d. Work with WAST on a Virtual Ward Model” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a post supporting the Chief Operating Officer’s team to increase urgent-care operational and escalation capacity.
Verbatim wording from the response “2. A new post supporting the Chief Operating Officer’s team to enhance capacity and focus on the urgent care system daily operating and escalation where appropriate.” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a proactive discharge project with Monmouthshire Local Authority at Nevill Hall Hospital.
Verbatim wording from the response “e. A focused project at Nevill Hall Hospital working with Monmouthshire Local Authority focused on proactive discharge arrangements to people’s own homes” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Urgent Care review meetings to challenge processes, review performance data and support collaborative working.
Verbatim wording from the response “1. Weekly review meetings with the Urgent Care Division chaired by the Chief Operating Officer and attended by the three Clinical Executive Directors (Medical Director, Director of Nursing & Director of Therapies and Health Science) and key Clinical Divisional colleagues. The purpose being:” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a discharge hub at Royal Gwent Hospital jointly with social care.
Verbatim wording from the response “b. Creation of a discharge hub at the Royal Gwent Hospital jointly with social care” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend Community Resource Team support for people with complex needs at home.
Verbatim wording from the response “c. Extending the Community Resource Team offer to support people with complex needs within the home” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Flow Centre to screen ambulance and GP admissions and stream patients to appropriate hospitals and departments.
Verbatim wording from the response “1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include:” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a business case for additional emergency-department consultants to reduce clinical assessment times.
Verbatim wording from the response “b. A new business case for additional ED Consultants to reduce clinical assessment times” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
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PFD Monitor interpretation Improve Same Day Emergency Care services and increase patient selection to release emergency-department and assessment capacity.
Verbatim wording from the response “2. Workstream 2 - Urgent & Emergency Care Redesign” Source location Response from Aneurin Bevan University Health Board
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create inter-specialty standards for emergency and assessment services.
Verbatim wording from the response “b. Creation of inter-speciality standards” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve community falls pathways, including head-injury and fractured-neck-of-femur pathways.
Verbatim wording from the response “f. Improvements in community falls including head injury and fractured neck of femur pathways” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ambulatory-care pathways, including respiratory and chest-pain pathways.
Verbatim wording from the response “e. Review of Ambulatory Care pathways including respiratory and chest pain pathways” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve internal handover processes for patients transferred from GUH to eLGH sites.
Verbatim wording from the response “b. Improving how the internal process for the handover of patients who are transferred from the GUH to the eLGH sites” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope and develop a collaborative Health Board–WAST workstream for alternatives to hospital conveyance.
Verbatim wording from the response “d. WAST referral line for agreed alternative to ED pathways within the Health Board to prevent direct ED attendances Initial scoping and commitment from the Health Board and WAST to create a collaborative working workstream, specifically looking at alternatives to hospital conveyance” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide consultant presence in the Flow Centre to support senior clinical decision-making.
Verbatim wording from the response “a. Consultant presence in the Flow Centre to aid senior clinical decision making” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve discharge-lounge use to create capacity and support ambulance handover times.
Verbatim wording from the response “3. Discharge Logistics” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign community-hospital services, including direct-access beds.
Verbatim wording from the response “b. Redesign of the model for community hospitals including Direct Access beds” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consolidate urgent-care and operational meetings into a single system-wide session with defined action owners and outcomes.
Verbatim wording from the response “We initially introduced these meetings as a dual-part format to address both the Urgent Care Emergency Department aspect and the broader operational approach, ensuring comprehensive coverage of all elements.” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a community falls response.
Verbatim wording from the response “c. Falls response in the community” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the escalation framework for ambulance handover delays.
Verbatim wording from the response “a. Revision of the escalation framework to ensure that the points of escalation during any ambulance handover delays are appropriate” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redirect clinically appropriate patients to eLGH sites for faster assessment and treatment.
Verbatim wording from the response “b. Redirection for specific conditions to eLGH sites rather than the GUH for more appropriate and rapid assessment and treatment” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot electronic triage in emergency-department and minor-injury-unit waiting rooms to improve efficiency and risk management.
Verbatim wording from the response “g. Pilot of an Electronic Triage system within the ED and MIU department waiting rooms to improve efficiency and risk management” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce discharge delays.
Verbatim wording from the response “3. Workstream 3 - Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Hospital to Home service providing additional community support.
Verbatim wording from the response “d. Creation of a Hospital to Home service to provide additional support within the community” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase substantive Physician Response Unit provision to deliver community emergency medicine and reduce emergency-department conveyance.
Verbatim wording from the response “3. A number of priority developments being tested and considered as part of the improvement programme.:” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Flow Centre clinical decision-making model and direct ambulance-service colleagues to appropriate receiving sites.
Verbatim wording from the response “c. Further review of the clinical decision-making model within the Flow Centre, ensuring that best clinical advice is provided and that WAST colleagues are directed to the most appropriate receiving site” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Ready to Go Ward and discharge floor at Royal Gwent Hospital to coordinate discharge and transition home.
Verbatim wording from the response “c. Creation of a Ready to Go Ward and a discharge floor at the Royal Gwent to bring together a discharge lounge, the Ready to Go Ward and an integrated hub to manage patients transition more effectively to their own home” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Patient Safety Flow meetings with defined action plans addressing patient flow and ambulance handover delays.
Verbatim wording from the response “Recent initiatives to improve patient flow and subsequent ambulance handover delays saw the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following workstreams:” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a single healthcare-professional telephone number for contact with alternative services.
Verbatim wording from the response “c. Single phone number for Health Care Professionals to enable a smoother contact process with alternative services including community frailty and Urgent primary Care” Source location Response from Aneurin Bevan University Health Board
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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 support for care homes.
Verbatim wording from the response “e. Greater support to Care Homes” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a permanent acute frailty team for frail and older patients.
Verbatim wording from the response “A number of priority workstreams are ongoing that have been instrumental in reducing handover delays within the Health Board. These have been streamed into three distinct workstreams:” Source location Response from Aneurin Bevan University Health Board
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