PFD report

Ester Jane Wood · Prevention of Future Deaths report

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Issued 6 Jun 2018•North Wales (East and Central)

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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 raised4

  1. Failure to maintain safe patient flow
    Part of recurring concern: Failure to maintain safe hospital patient flow
  2. Unavailability of required healthcare resources
  3. Delays in ambulance response or conveyance
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 maintain safe patient flow

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe hospital patient flow.

Open source report

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

Unavailability of required healthcare resources

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 ambulance response or conveyance

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 ensure timely admission to the emergency department

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”

Is this part of a recurring concern?

Yes — Failure to provide timely hospital admission.

Open source report
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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