PFD report

Rashdah Waseem Begum Bhatti · Prevention of Future Deaths report

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Issued 12 Sep 2023•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Concerns raised1

  1. Failure of handlers to follow the appropriate MPDS pathway for providing clinically beneficial advice
    Part of recurring concern: Unreliable Medical Priority Dispatch System emergency assessment and advice pathways
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.4

  1. Action

    Undertake improvement actions identified through the further targeted audit.

    Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
  2. Action

    Issue all call handlers a reminder about correctly using Post-Dispatch Instructions.

    Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
  3. Action

    Complete a focused audit of protocol 21 calls and Post-Dispatch Instructions.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.

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 of handlers to follow the appropriate MPDS pathway for providing clinically beneficial advice

Wider context from the report

“The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object” Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased. Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway. ”

Is this part of a recurring concern?

Yes — Unreliable Medical Priority Dispatch System emergency assessment and advice pathways.

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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

Undertake improvement actions identified through the further targeted audit.

Verbatim wording from the response

“During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 15 September 2023

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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

Issue all call handlers a reminder about correctly using Post-Dispatch Instructions.

Verbatim wording from the response

“During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 15 September 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

Complete a focused audit of protocol 21 calls and Post-Dispatch Instructions.

Verbatim wording from the response

“During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 15 September 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

Undertake a further targeted audit of protocol 21 calls to verify correct delivery of Post-Dispatch Instructions.

Verbatim wording from the response

“During October 2023 we undertook a focused audit of calls in relation to protocol 21 (Haemorrhage/laceration). During the month 89 audits regarding that protocol were undertaken and 3 errors identified in relation to PDIs. This equates to 3% of the calls. As a result of the targeted audit, we will issue a reminder to all call handlers regarding the use of PDIs, before the end of this calendar year. The Trust will undertake a further targeted audit in February 2024, to ensure that PDIs are being given correctly and any identified improvement actions will be undertaken accordingly. I would like to extend my sincere condolences to Mrs Bhatti’s family on their sad loss.”

Source location

Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 15 September 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