PFD report

Barbara YOUNG · Prevention of Future Deaths report

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Issued 28 Jan 2022•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
16

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 providing a timely emergency ambulance response
    Part of recurring concern: Delays in ambulance attendance
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.13

  1. Action

    Work with Health Boards to minimise hospital handover delays through on-site support and prioritisation of patients with greatest clinical need.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
  2. Action

    Support out-of-hours patient discharge and transfer to release hospital beds and improve emergency-department flow.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  3. Action

    Increase the pan-Wales workforce by 236 full-time-equivalent staff through recruitment and training.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.

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

  1. Position

    System pressures, including hospital handover delays and staffing impacts, limit the Trust’s ability to provide the desired ambulance response level.

    Stated by Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 providing a timely emergency ambulance response

Wider context from the report

“I am informed that the risk of mortality in the elderly who have suffered significant trauma is high, because they are at greater risk of developing pneumonia. It is therefore essential that they receive emergency medical care as soon as possible. In this case it took 3 hours for an ambulance to arrive and whilst I have no evidence that this delay contributed to Mrs Young’s death similarly I cannot confirm it did not, and that future lives could be at risk due to the delays in providing a timely emergency response. I acknowledge the problems faced by the ambulance service over the last 2 years, problems that have been compounded by the effects of the pandemic and delays in transferring patients into hospital emergency departments. I have also been informed that there have been plans in place to improve the responsiveness of the service however from the evidence provided at this inquest it appears that problems still exist. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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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

Work with Health Boards to minimise hospital handover delays through on-site support and prioritisation of patients with greatest clinical need.

Verbatim wording from the response

“Handover Delays”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 2 · response
Published 3 February 2022

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 out-of-hours patient discharge and transfer to release hospital beds and improve emergency-department flow.

Verbatim wording from the response

“Discharge and Transfer”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 3 · response
Published 3 February 2022

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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

Increase the pan-Wales workforce by 236 full-time-equivalent staff through recruitment and training.

Verbatim wording from the response

“Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. The staff have been recruited and trained as part of our established Emergency Medical Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 22/23 to ensure staff are on duty at the time and in the place that best match patient demand. This will release an internal efficiency equivalent to 72 FTE.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 4 · response
Published 3 February 2022

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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 falls Medical Priority Dispatch System codes and assign four suitable codes directly to Falls Assistants without clinical triage.

Verbatim wording from the response

“The Trust continues to work with partners to further expand the model, to ensure patients are able to receive a timely response. In December the Trust undertook a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response. Following a review, four codes were identified as suitable for Falls Assistants (non-registered, in some areas St John Service) to attend without the need for Clinical Triage, thus reducing the requirement to send an Emergency Ambulance. Furthermore, improvements are actively being considered to improve utilisation of resources and support patients who are waiting for a response. A Quality Improvement Workshop has been prioritised for April, with representatives from across the organisation to identify tests of change and prioritise improvements.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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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 reviewing and updating falls and frailty dispatch guidance to optimise resource use and support correct outcomes.

Verbatim wording from the response

“CSD clinicians have the ability to change the responding priority of an incident based on a secondary clinical assessment, this includes increasing the priority where the patient’s clinical acuity indicates this is appropriate. Dispatch guidelines regarding falls and frailty responders are continually reviewed and updated to ensure maximum utilisation of this valuable resource, part of the CSD role is to provide support to falls assistants following an initial assessment to ensure the correct outcome is reached.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 4 · response
Published 3 February 2022

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

Reroster all staff during the third quarter of 2022–23 to align staffing with patient demand and release internal efficiency.

Verbatim wording from the response

“Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. The staff have been recruited and trained as part of our established Emergency Medical Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 22/23 to ensure staff are on duty at the time and in the place that best match patient demand. This will release an internal efficiency equivalent to 72 FTE.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 4 · response
Published 3 February 2022

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

Continue recruiting and training Advanced Paramedic Practitioners to treat suitable patients in their homes and reduce unnecessary emergency-department conveyance.

Verbatim wording from the response

“Reducing Conveyance to ED Departments”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 3 · response
Published 3 February 2022

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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

Double Clinical Contact Centre clinical staffing to reduce unnecessary ambulance dispatches and conveyance.

Verbatim wording from the response

“Consult and Close”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 2 · response
Published 3 February 2022

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 and use the enhanced Clinical Safety Plan to manage extreme pressure, communicate delays, and protect responses for immediately life-threatening conditions.

Verbatim wording from the response

“Clinical Safety Plan (CSP)”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 3 · response
Published 3 February 2022

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

Work with community first responders and Fire and Rescue Services to provide designated responses for patients who have fallen.

Verbatim wording from the response

“In addition to the specialist falls response, the Trust are working with volunteers (community first responders) and Fire and Rescue Services to provide a designated response to patients who have fallen to ensure periods of immobility are reduced. Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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

Maintain the Falls Assistant response model, including the National Falls Assistant Service and additional Trust-funded night vehicles.

Verbatim wording from the response

“Additionally, in 2018, Working in partnership with St John Cymru Wales, the Trust introduced the role of the Falls Assistants (FA). The FA predominately provide a response to patients who have no injuries or where there is a concern for welfare. However, they are able to respond to patients with other medical/fragile presentations, or if there is an injury. This decision will often be supported by a clinical triage and assessment by a clinician, over the phone, prior to allocation. The aim of this new level of response was to ensure those patients often presenting with lower clinical acuity, were provided with a timely response to reduce the risk of further harm.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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

Recruit Patient Flow Coordinators and secure winter private ambulance clinician support to facilitate safe, timely hospital transfers.

Verbatim wording from the response

“with assistance from nursing and medical staff, prioritising those patients with the greatest clinical need. As an example, a number of Patient Flow Coordinators have been recruited to support the wider system flow pressures at the Grange Hospital, Cwmbran. In addition, we secured support from Private Ambulance Service clinicians over the winter months. The purpose of the approach is to facilitate safe timely transfers for a cohort of patients from the Trust ambulances when there is no capacity within the Emergency Department (ED) or elsewhere in the hospital to facilitate timely off-load. That said, delayed transfer of care remains a significant barrier our ability to respond to calls in the community in a timely fashion with 25% of our on duty fleet capacity lost in this way in February.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 3 · response
Published 3 February 2022

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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

Refer elderly falls categorisation to the Clinical Priority Software Advisory Group for consideration.

Verbatim wording from the response

“The appropriateness of the priority given to each category of call is reviewed and changes are considered by the Trust’s Clinical Priority Software Advisory Group (CPAS). In all cases the group will consider the impact any change would have on the volume of each priority of calls received, for example the effect of increasing the number of Red calls would have an impact on all other codes. The CPAS group also sets an “ideal” response for each type of call, in an attempt to maximise efficient use of resources by avoiding “double dispatch” on calls.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 4 · response
Published 3 February 2022

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

System pressures, including hospital handover delays and staffing impacts, limit the Trust’s ability to provide the desired ambulance response level.

Verbatim wording from the response

“I am able to provide you with absolute assurance that the negative and sometimes catastrophic impact the systems pressures are having on patients in our communities is constantly being reviewed and escalated at the highest level. I can also assure you, that the Trust has already taken many actions to try and mitigate the effects of ambulances being delayed at hospital, which then effects our ability to respond to people in the community. As I am sure you will appreciate, none of these matters sit in isolation but are interlinked. I wish to assure you that the Trust has made several changes and taken actions, over and above those I have listed here. However, I have selected the issues and actions that I hope best demonstrates that the Trust has considered every possible way in which we can react to and mitigate the impact of these pressures, which are fundamentally outside of our control.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 2 · response
Published 3 February 2022

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.3

  1. 1

    Introduce enhanced Clinical Contact Centre desk capacity to provide targeted advice, including pressure-ulcer prevention and reducing immobility while patients await response.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
  2. 2

    Review post-fall patient guidance, including advice provided through 999, risks from immobility, and response availability and capacity.

    Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
  3. 3

    Hold a cross-organisational Quality Improvement Workshop to identify and prioritise falls-response tests of change.

    Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.

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

Introduce enhanced Clinical Contact Centre desk capacity to provide targeted advice, including pressure-ulcer prevention and reducing immobility while patients await response.

Verbatim wording from the response

“In addition to the specialist falls response, the Trust are working with volunteers (community first responders) and Fire and Rescue Services to provide a designated response to patients who have fallen to ensure periods of immobility are reduced. Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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

Review post-fall patient guidance, including advice provided through 999, risks from immobility, and response availability and capacity.

Verbatim wording from the response

“This includes a review of the advice provided via 999 and a review of the response availability and capacity. The Falls Improvement and Implementation Group (FIIG) will conduct a review of the guidance provided to patients following a fall, consider the risks associated immobility and will suggest possible improvements.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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

Hold a cross-organisational Quality Improvement Workshop to identify and prioritise falls-response tests of change.

Verbatim wording from the response

“The Trust continues to work with partners to further expand the model, to ensure patients are able to receive a timely response. In December the Trust undertook a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response. Following a review, four codes were identified as suitable for Falls Assistants (non-registered, in some areas St John Service) to attend without the need for Clinical Triage, thus reducing the requirement to send an Emergency Ambulance. Furthermore, improvements are actively being considered to improve utilisation of resources and support patients who are waiting for a response. A Quality Improvement Workshop has been prioritised for April, with representatives from across the organisation to identify tests of change and prioritise improvements.”

Source location

2022-0027-Response-from-Welsh-Ambulance-Service-NHS-Trust_Published
Page 5 · response
Published 3 February 2022

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