PFD report

Mary Elizabeth Jones · Prevention of Future Deaths report

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Issued 10 Jul 2023•North West Wales

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
3

Raised in this report

Recipients
8

Named on the report

Responses found
1

Of 8 recipients

Stated actions
5

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 raised3

  1. Delays in ambulance response and arrival
    Part of recurring concern: Delays in ambulance attendance
  2. Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies
    Part of recurring concern: Unreliable coordination of social-care-related patient flow
  3. Inability to offload patients from ambulances into Emergency Departments in a timely manner
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
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.5

  1. Action

    Maintain and regularly critique and monitor the Clinical Safety Plan and Regional Escalation Action Plan across the organisation.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
  2. Action

    Take all possible steps within the Trust’s control to ensure resources are available for Red and Amber calls.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
  3. Action

    Liaise directly with Health Boards and wider health and social care partners to secure support for timely responses to Red and Amber calls.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing plans, monitoring and escalation arrangements are considered sufficient to manage timely responses to Red and Amber calls.

    Stated by The TrustExisting 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

Delays in ambulance response and arrival

Wider context from the report

“This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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 involve Local Authorities in considerations of patient flow affected by social care deficiencies

Wider context from the report

“This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of social-care-related 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

Inability to offload patients from ambulances into Emergency Departments in a timely manner

Wider context from the report

“This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover.

Open source report

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

Maintain and regularly critique and monitor the Clinical Safety Plan and Regional Escalation Action Plan across the organisation.

Verbatim wording from the response

“The Trust has evidenced this work through the comprehensive details of all the actions that we have taken to date, and I have also shared with you the measures that are currently in place, such as the Clinical Safety Plan and the Regional Escalation Action Plan. I have not attached copies of these Plans again, as I have previously supplied them.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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

Take all possible steps within the Trust’s control to ensure resources are available for Red and Amber calls.

Verbatim wording from the response

“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust 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 Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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

Liaise directly with Health Boards and wider health and social care partners to secure support for timely responses to Red and Amber calls.

Verbatim wording from the response

“To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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

Seek Welsh Government, NHS and local-government support for clinical risk management across urgent and emergency care pathways to release Trust resources.

Verbatim wording from the response

“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust 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 Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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

Present and review the Real-time Mitigation Report and Reducing Patient Harm Action Plan at Trust Board meetings.

Verbatim wording from the response

“I have shared with you copies of the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, both of which were presented to the Public Trust Board on the 27 July 2023. This Report is regularly presented to, and reviewed by, the Trust Board and I hope this offers you assurance that this matter continues to remain a significant risk and a matter of attention to the full Trust Board.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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

Existing plans, monitoring and escalation arrangements are considered sufficient to manage timely responses to Red and Amber calls.

Verbatim wording from the response

“To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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 further or new action is proposed in response to the concerns.

Verbatim wording from the response

“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust 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 Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Trust considers it lacks authority to take the actions contemplated by the Prevention of Future Deaths report.

    Stated by The TrustOutside remitThe respondent said that this matter was outside its role or authority.

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 considers it lacks authority to take the actions contemplated by the Prevention of Future Deaths report.

Verbatim wording from the response

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

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023

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