PFD report

Robyn Anne Chambers · Prevention of Future Deaths report

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Issued 22 Jul 2025•Gwent

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
23

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 raised1

  1. Delays in releasing ambulances from emergency departments
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Action

    Appoint a dedicated Associate Director of Clinical Operations to strengthen senior clinical leadership for patient flow and handover-delay escalation.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 25 July 2025.
  2. Action

    Continue the focused Handover 45 initiative to reduce ambulance handover delays and sustain performance improvements.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2025.
  3. Action

    Embed the national optimal hospital flow framework, including standardized board rounds, across acute and community hospitals in Gwent.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    WAST was responsible for contacting the Health Board through approved routes to request release of a delayed ambulance vehicle.

    Stated by Aneurin Bevan University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 releasing ambulances from emergency departments

Wider context from the report

“However, having heard evidence from Welsh Ambulance Service NHS Trust, I note that the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital. Evidence provided at inquest indicated that, at the time that Robyn’s parents called for an ambulance, the longest time an ambulance was delayed at the GUH was in excess of 10 hours. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Appoint a dedicated Associate Director of Clinical Operations to strengthen senior clinical leadership for patient flow and handover-delay escalation.

Verbatim wording from the response

“5. Leadership and Culture”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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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 the focused Handover 45 initiative to reduce ambulance handover delays and sustain performance improvements.

Verbatim wording from the response

“d. A national Ministerial Action Group is currently working on a national workstream aiming for no delays over 45 minutes across Wales which we are hugely committed to. This ‘Handover 45’ workstream mandates that there will be no over 45-minute delays from November 2025 in Wales. The Health Board has already commenced a focused initiative based on this approach early September with early indications of positive progress.”

Source location

Response from Aneurin Bevan University Health Board
Page 4 · response
Published 25 July 2025

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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

Embed the national optimal hospital flow framework, including standardized board rounds, across acute and community hospitals in Gwent.

Verbatim wording from the response

“4. Discharge”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the Emergency Pressures Escalation Policy against NHS Wales urgent and emergency care escalation guidance.

Verbatim wording from the response

“b. Reviewed our Emergency Pressures Escalation Policy to ensure it aligns with the NHS Wales Guidance ‘A Framework for Urgent & Emergency Care System”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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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

Maximize capacity of the dedicated Transfer and Discharge Lounge at Grange University Hospital.

Verbatim wording from the response

“b. Maximize capacity of the dedicated Transfer & Discharge Lounge at the Grange University Hospital”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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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 weekly scrutiny panels and improved system escalation to focus on longest-staying patients.

Verbatim wording from the response

“d. Focus on longest-staying patients via weekly scrutiny panels and improved system escalation”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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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

Appoint six additional whole-time-equivalent Emergency Department consultants to increase assessment and treatment capacity.

Verbatim wording from the response

“• The business case for additional ED Consultants to reduce clinical assessment times was approved with the Health Board appointing a further 6 whole time equivalent ED Consultants. All will have commenced their new roles by September 2025. This will improve assessment and treatment capacity which will reduce waits and increase throughput of patients.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop a criteria-led discharge approach using agreed clinical criteria for timely and safe discharge.

Verbatim wording from the response

“e. Develop a criteria led discharge approach that uses agreed clinical criteria to ensure timely and safe discharge”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the internal Immediate Release Protocol for compliance with WAST’s revised purple 999 response.

Verbatim wording from the response

“WAST, in conjunction with the Health Boards operating an ‘Immediate Release Direction Protocol’ which outlines the principles and processes for the management of immediate release directions that includes a dynamic escalation process to, as far as possible, minimise patient safety risk for patients awaiting a response in our communities when ambulance capacity is reduced or when the time for patient handover at emergency departments is extended (the handover standard is 15 minutes and considered extended beyond 30 minutes). Review of the internal Immediate Release Protocol is being undertaken to ensure compliance with WAST’s revised ‘purple’ 999 response.”

Source location

Response from Aneurin Bevan University Health Board
Page 4 · response
Published 25 July 2025

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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

Refresh weekly whole-system flow oversight with senior executive chairing and action plans for emergency care and ambulance handover delays.

Verbatim wording from the response

“In terms of oversight and actions, the Health Board has refreshed its weekly oversight arrangements and changed the focus to whole system flow with the chair now being the Chief Operating Officer, with the Chief Executive chairing every fourth week. Input is also received from the Clinical Executives. These meetings include a clear focus on the delivery and performance of the Health Board’s Emergency Department and Minor Injury Units with very clear action plans to mitigate the risk and seek improvements in”

Source location

Response from Aneurin Bevan University Health Board
Page 1 · response
Published 25 July 2025

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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

Operate the larger transfer lounge opened at Grange University Hospital to support earlier transfer of patients from the Emergency Department.

Verbatim wording from the response

“• A new larger transfer lounge opened in March 2025 which has capacity of 25 spaces (including chairs and beds) which will support flow throughout the day enabling earlier transfer of patients from the ED department to the relevant ward areas.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop a digital platform showing patient status at each pathway stage to improve patient flow.

Verbatim wording from the response

“c. Development of digital platform to enhance visibility to patient status at each stage of the pathway, enabling improved patient flow”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

WAST was responsible for contacting the Health Board through approved routes to request release of a delayed ambulance vehicle.

Verbatim wording from the response

“During 26 October, whilst noting that the Health Board did have significant challenges with adhering to the nationally agreed 15-minute ambulance handover time, WAST did not contact the Health Board via approved routes to ask for a vehicle to be released. The 999 call to attend to Robyn Chambers had been upgraded and coded as an amber 1 response and fell within the provision of the Immediate Release Direction Protocol. Had this occurred, the Health Board would have endeavoured, as per the protocol to release a delayed vehicle to respond as requested.”

Source location

Response from Aneurin Bevan University Health Board
Page 4 · response
Published 25 July 2025

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.11

  1. 1

    Develop a process improving front-door responsiveness for non-injurious falls patients conveyed to hospital.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  2. 2

    Increase use of the established falls system navigation pathway to identify appropriate locations for initial assessment.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  3. 3

    Implement a consistent seven-day community falls response service in partnership with WAST.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  4. 4

    Implement clinical multidisciplinary review of suitable single-point-of-access referrals to identify alternative pathways.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  5. 5

    Implement daily Safe to Start meetings co-chaired by senior nursing and operations teams to resolve ward safety issues in real time.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 25 July 2025.
  6. 6

    Provide care-home equipment, training and future care-plan development to reduce hospital conveyances and support care closer to home.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  7. 7

    Implement direct access to community beds for appropriate frail patients to avoid acute admission.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  8. 8

    Deliver a single-point-of-access navigation hub for health-professional referrals into the Health Board.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  9. 9

    Embed advanced Paramedic Practitioner capacity within the navigation hub to assess waiting calls and prevent unnecessary attendances and admissions.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  10. 10

    Align community and front-door frailty teams to identify frail patients and support discharge home.

    Stated by Aneurin Bevan University LHBStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 July 2025.
  11. 11

    Complete the Emergency Department extension to provide additional clinical assessment spaces.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 July 2025.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop a process improving front-door responsiveness for non-injurious falls patients conveyed to hospital.

Verbatim wording from the response

“c. Develop a process to improve Front door responsiveness for non-injurious falls patients conveyed to hospital”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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

Increase use of the established falls system navigation pathway to identify appropriate locations for initial assessment.

Verbatim wording from the response

“b. Increase utilization of the established falls system navigation pathway to identify the most appropriate location for initial assessment”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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

Implement a consistent seven-day community falls response service in partnership with WAST.

Verbatim wording from the response

“1. Community Falls Response”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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

Implement clinical multidisciplinary review of suitable single-point-of-access referrals to identify alternative pathways.

Verbatim wording from the response

“c. Implement a clinical MDT review of appropriate patients referred into the single point of access with the aim of identifying appropriate alternative pathways”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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

Implement daily Safe to Start meetings co-chaired by senior nursing and operations teams to resolve ward safety issues in real time.

Verbatim wording from the response

“c. Implemented the ‘Safe to Start’ agenda, looking at whether clinical wards can provide a safe environment in which to commence each day. These meetings commence daily at 08:20 are co-chaired by the Senior Nursing and Operations teams and provide clarity on each ward’s position so that any issues identified are resolved in real time and collaboratively.”

Source location

Response from Aneurin Bevan University Health Board
Page 4 · response
Published 25 July 2025

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

Provide care-home equipment, training and future care-plan development to reduce hospital conveyances and support care closer to home.

Verbatim wording from the response

“3. Frailty”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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

Implement direct access to community beds for appropriate frail patients to avoid acute admission.

Verbatim wording from the response

“b. Implement direct access to community beds for appropriate frail patients thus avoiding admission to an acute setting”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

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

Deliver a single-point-of-access navigation hub for health-professional referrals into the Health Board.

Verbatim wording from the response

“2. Single Point of Access”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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 advanced Paramedic Practitioner capacity within the navigation hub to assess waiting calls and prevent unnecessary attendances and admissions.

Verbatim wording from the response

“b. Partner with WAST to embed advanced Paramedic Practitioner capacity within the navigation Hub to undertake assessment of waiting calls and interventions to prevent unnecessary attendances and admissions”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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

Align community and front-door frailty teams to identify frail patients and support discharge home.

Verbatim wording from the response

“c. Aligning community and front door frailty teams to identify frail patients within the Emergency department and assessment units aiming to enable discharge home with appropriate support”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 25 July 2025

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Complete the Emergency Department extension to provide additional clinical assessment spaces.

Verbatim wording from the response

“• The new ED extension is due for completion in the next few months which will offer additional assessment spaces for the clinical teams in addition to improved patient experience.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 25 July 2025

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