PFD report

Jeanette Sidlow Beech · Prevention of Future Deaths report

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Issued 29 May 2025•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
3

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

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 attendance
    Part of recurring concern: Delays in ambulance attendance
  2. Lack of social care and community hospital capacity for discharge and onward bed availability
    Part of recurring concern: Failure to provide timely suitable onward care placements for patients ready for hospital dischargePart of recurring concern: Insufficient social and community care provision to meet care and discharge needs
  3. Delays in hospital handover of ambulances
    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.7

  1. Action

    Compile evidence on effective ambulance handover strategies and develop an improvement programme and readiness assessment.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
  2. Action

    Monitor health-board progress against ambulance handover actions through Integrated Quality Planning and Delivery meetings.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
  3. Action

    Complete the compliance review of ambulance patient handover guidance and share its findings with health boards.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Welsh Ministers set strategic expectations but are not responsible for delivering health services.

    Stated by Welsh GovernmentOutside remitThe respondent said that this matter was outside its role or authority.

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 attendance

Wider context from the report

“a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful. b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays. c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST. d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons. e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours. f. The issues identified are pertinent to WAST, the Health Board and Local Authorities. g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists. ”

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

Lack of social care and community hospital capacity for discharge and onward bed availability

Wider context from the report

“a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful. b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays. c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST. d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons. e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours. f. The issues identified are pertinent to WAST, the Health Board and Local Authorities. g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists. ”

Is this part of a recurring concern?

Yes — Failure to provide timely suitable onward care placements for patients ready for hospital discharge; Insufficient social and community care provision to meet care and discharge needs.

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 hospital handover of ambulances

Wider context from the report

“a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful. b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays. c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST. d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons. e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours. f. The issues identified are pertinent to WAST, the Health Board and Local Authorities. g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists. ”

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

Compile evidence on effective ambulance handover strategies and develop an improvement programme and readiness assessment.

Verbatim wording from the response

“The taskforce will use the NHS Performance and Improvement review as a foundation and will compile comprehensive evidence on effective strategies for improving ambulance patient handover. This will inform the development of an improvement programme and a readiness assessment.”

Source location

Response from Welsh Government
Page 3 · response
Published 17 June 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

Monitor health-board progress against ambulance handover actions through Integrated Quality Planning and Delivery meetings.

Verbatim wording from the response

“My officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects in this report to support compliance with the handover guidance and work towards delivery of no delays of more than 45 minutes by quarter three in 2025-26. Progress will be closely monitored by the Welsh Government and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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 compliance review of ambulance patient handover guidance and share its findings with health boards.

Verbatim wording from the response

“To support health boards, my officials arranged a review of compliance with the ambulance patient handover guidance during the last quarter of 2024-25, which was completed by March 2025 by NHS Performance and Improvement. A report detailing the findings and key themes for health boards was shared on 18 June. A copy is attached at annex A.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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

Seek urgent assurance from each health board on actions to comply with ambulance handover guidance.

Verbatim wording from the response

“My officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects in this report to support compliance with the handover guidance and work towards delivery of no delays of more than 45 minutes by quarter three in 2025-26. Progress will be closely monitored by the Welsh Government and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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

Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.

Verbatim wording from the response

“We have made an additional £2.7m available to the health board this year to support delivery of local improvement plans. This is part of £35.5m to support the health board and the North Wales Regional Partnership Board to safely manage more people in the community; to avoid ambulance transport and admission to hospital; and deliver integrated solutions with social care services to improve patient flow through hospitals. The impact made by the region is being closely monitored.”

Source location

Response from Welsh Government
Page 4 · response
Published 17 June 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

Support health boards and WAST to improve ambulance handover performance toward 15-minute handovers and a 45-minute backstop.

Verbatim wording from the response

“It will support all health boards and WAST to improve handover performance, working towards delivery of a standard ambulance patient handover within 15 minutes, with a backstop of 45 minutes.”

Source location

Response from Welsh Government
Page 3 · response
Published 17 June 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

Establish the clinically led National Handover-45 Taskforce.

Verbatim wording from the response

“To further drive improvements, I announced on 30 June, a clinically-led National Handover-45 Taskforce – the details are set out in this Written Statement.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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

Welsh Ministers set strategic expectations but are not responsible for delivering health services.

Verbatim wording from the response

“Welsh Ministers set the strategic context and expectations for health and care services in Wales and hold NHS organisations accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.”

Source location

Response from Welsh Government
Page 1 · response
Published 17 June 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 is responsible for delivering emergency ambulance services, while the JCC commissions those services.

Verbatim wording from the response

“The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 established the Welsh Ambulance Services University National Health Service Trust (WAST). Article 3 delegates the function of managing the ambulance service to WAST.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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

Health boards are responsible for planning, commissioning and delivering local health services within the national policy framework.

Verbatim wording from the response

“Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their local areas, in line with the national policy framework set by Welsh Ministers.”

Source location

Response from Welsh Government
Page 1 · response
Published 17 June 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

Health boards are responsible for ensuring ambulance handovers occur reliably and that receiving hospitals have sufficient capacity.

Verbatim wording from the response

“The Welsh Government’s policy expectation of health boards is that when a patient is conveyed to a hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.”

Source location

Response from Welsh Government
Page 2 · response
Published 17 June 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.2

  1. 1

    Provide Welsh Government, urgent-care programme and NHS Performance and Improvement support to the health board’s service improvements.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2025.
  2. 2

    Chair the Winter Summit and issue winter emergency-care expectations, guidance and good practice to NHS and local-authority partners.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 17 June 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

Provide Welsh Government, urgent-care programme and NHS Performance and Improvement support to the health board’s service improvements.

Verbatim wording from the response

“As part of the special measures intervention, the health board receiving support from the Welsh Government, the Six Goals for Urgent and Emergency Care programme and NHS Performance and Improvement to make the necessary improvements to the quality and timeliness of its urgent and emergency care services and the experience of patients accessing its services.”

Source location

Response from Welsh Government
Page 4 · response
Published 17 June 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

Chair the Winter Summit and issue winter emergency-care expectations, guidance and good practice to NHS and local-authority partners.

Verbatim wording from the response

“As the winter period traditionally presents greater challenges for emergency care services, the process of learning lessons from last winter and developing plans for winter 2025-26 started at the earliest possible stage, on 31 March. I chaired a Winter Summit meeting with NHS chief executives, directors of social services and the Association of Directors of Social Services (ADSS) Cymru.”

Source location

Response from Welsh Government
Page 3 · response
Published 17 June 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