PFD report

Rebecca Anne Evans · Prevention of Future Deaths report

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Issued 14 Mar 2017•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
19

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. Patient flow failing to enable admission of patients requiring treatment
    Part of recurring concern: Failure to maintain safe hospital patient flowPart of recurring concern: Failure to provide timely hospital admission
  2. Delays in admission to hospital
    Part of recurring concern: Failure to provide timely hospital admission
  3. Delays in handover of patients at an Emergency Department
    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.10

  1. Action

    Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. Action

    Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. Action

    Coordinate immediate emergency-department offload with WAST to release ambulances for potentially life-threatening calls.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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

Patient flow failing to enable admission of patients requiring treatment

Wider context from the report

“3. It is of grave concern to me that my statutory duty requires me to report these concerns by way of regulation 28 reports on a very regular basis and that despite previous such reports there continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe hospital patient flow; Failure to provide timely hospital admission.

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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 admission to hospital

Wider context from the report

“1. That there were significant delays in the admission of Ms Evans to Hospital and that medical treatment was consequently not commenced in a timely manner. ”

Is this part of a recurring concern?

Yes — Failure to provide timely hospital admission.

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 handover of patients at an Emergency Department

Wider context from the report

“2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”

Is this part of a recurring concern?

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

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 ambulance resources for allocation to other calls

Wider context from the report

“2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”

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

Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.

Verbatim wording from the response

“Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached. The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target.”

Source location

2017-0077-Response-by-University-Health-Board
Page 1 · response
Published 24 March 2017

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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

Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.

Verbatim wording from the response

“The use of information within Unscheduled Care decision making There is extensive use of predictive tools and modeling within our overall approach to Unscheduled Care. The overall capacity and demand model developed by the planning section has informed the scale of improvement required to achieve a bed occupancy level of 85%. The metrics within the overall plan are calibrated at a level which has been calculated to enable the 4 hour target to be achieved and improve ambulance handover.”

Source location

2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017

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

Coordinate immediate emergency-department offload with WAST to release ambulances for potentially life-threatening calls.

Verbatim wording from the response

“16. Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST) they co-ordinate with emergency department to ensure that ambulances can be released to respond to potentially life threatening calls through immediate offload into any available in ED.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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

Engage ambulance locality leads and implement a Minor Injuries Unit procedure to redirect suitable cases from emergency ambulance pathways.

Verbatim wording from the response

“4. Emergency Departments and WAST; WAST locality Leads are engaged on both sites supporting non-conveyance options for EMS activity. This includes the formal Minor Injuries Units Stand Operating Procedure to redirect suitable clinical cases to MIUs.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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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

Operate regular ambulance-patient checks, diagnostics and treatment reviews to minimise delays.

Verbatim wording from the response

“15. Regular Review of Patient delayed in Ambulances; to help prevent recurrence of the issues you raised relating to Rebecca Evans a system of regular checks, diagnostics and treatment, has been put in place to ensure patients experience the minimum delay.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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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

Develop surge-capacity arrangements for peak evening and overnight demand using previously unstaffed clinical space.

Verbatim wording from the response

“11. Evening / Overnight Capacity; all sites have developed surge capacity options to meet periods of peak demand during the evening and overnight. This utilizes physical capacity that would not normally be staffed overnight, therefore increasing capacity and utilization of core clinical estate.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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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

Strengthen out-of-hours site management through twilight managers, a new clinical rota, additional night sisters and a senior manager role.

Verbatim wording from the response

“7. Operational site management; WMH have employed twilight site managers to support evening bed pressures. All three acute hospitals in the Health Board are moving towards a new out of hours site management clinical rota to support flow and response to escalation. This includes additional night sisters to support core site management. WMH also provide a Senior Manager of the day who works till 8pm to support decompression of acute problems affecting flow.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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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

Develop a revised Bronze and Silver on-call model with dedicated 24-hour Silver cover, clinical support and strengthened site-management resilience.

Verbatim wording from the response

“10. Senior Manager Bronze and Silver on call arrangements; a formal review of Bronze and Silver on call manager rotas in recognition of the demands of unscheduled care pressures has informed the development of a new model. This includes”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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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

Use medical-fit-for-discharge data to develop escalation pathways and teams, including the YGC Step Down Team, for alternative discharge or transfer options.

Verbatim wording from the response

“12. Development of Medical Fit to Discharge data; WMH and YGC have used data extracted specifically from WPAS and local data collection to identify patients fit for discharge but delayed due to factors outside of the acute hospital control. This has resulted in the development of new escalation pathways and teams, such as the Step Down Team at YGC to secure alternative discharge / transfers options for MFDs contributing to bed blockages and bed turn over.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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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 emergency-department capacity by opening additional minor-attendance rooms and converting trolley space into a four-chair ambulatory area.

Verbatim wording from the response

“6. Emergency department Capacity; both EDs have reviewed the demand profiles and commissioned additional clinical capacity. WMH have opened two additional examination rooms for minor attendances to protect the minors stream. YGC have converted one minors trolley space to a four chair ambulatory area to increase minors stream capacity.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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.9

  1. 1

    Increase emergency-department nursing, healthcare support worker and physician assistant capacity to match demand.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. 2

    Allocate clinical psychology resources to lead multidisciplinary, multi-agency action plans for frequent service users.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. 3

    Engage Public Health Wales to understand higher 999 demand and use the findings to inform service planning.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  4. 4

    Integrate emergency-department and out-of-hours GP services and continue developing redirection to co-located satellite facilities.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 24 March 2017.
  5. 5

    Appoint extended-scope physiotherapists and provide seasonal GP support to stream suitable patients away from main emergency pathways.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  6. 6

    Strengthen executive oversight of out-of-hours escalation and appoint a lead executive to engage with the Welsh Government Delivery Unit.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  7. 7

    Implement patient navigators at YGC Emergency Department to redirect and expedite care for walk-in attenders.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  8. 8

    Roll out treatment escalation plans for palliative and terminally ill patients across BCU.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 24 March 2017.
  9. 9

    Increase emergency-department consultant presence through revised medical rotas at WMH and YGC.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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 emergency-department nursing, healthcare support worker and physician assistant capacity to match demand.

Verbatim wording from the response

“2. Nursing Rotas; Since YGC opened the new Emergency Department in June 2014 the nursing staff have been significantly increased to ensure staffing meets demand especially in the evening, weekend and over night. WMH have increased twilight shifts to meet evening demand. Both WMH and YGC Emergency Departments have increased their Health Care Support Workers capacity and increased Physician Assistant roles to meet demand and improve timeliness.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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

Allocate clinical psychology resources to lead multidisciplinary, multi-agency action plans for frequent service users.

Verbatim wording from the response

“9. Frequent service Users; data on both Emergency Department attendances and acute admission into medicine from frequent service users (more than 4 attendances / admissions in a rolling 12 months) has resulted in resources being”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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

Engage Public Health Wales to understand higher 999 demand and use the findings to inform service planning.

Verbatim wording from the response

“8. Ambulance Conveyances; YGC has engaged with Public Health Wales to understand the higher 999 demand experienced at YGC. This work is informing a number of plans including the development of a minor injuries unit within the north Denbighshire project at the Royal Alexandra hospital site.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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

Integrate emergency-department and out-of-hours GP services and continue developing redirection to co-located satellite facilities.

Verbatim wording from the response

“3. GP Out of Hours; both YGC and WMH have worked to create an integrated platform to deliver services that support patients moving from ED to GP Out of Hours to reduce demand on the minors ED streams. This redirection continues to evolve with further work supporting satellite GP Out of Hours facilities co-located with Minor Injury units for example at Llandudno Hospital.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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

Appoint extended-scope physiotherapists and provide seasonal GP support to stream suitable patients away from main emergency pathways.

Verbatim wording from the response

“5. Alternative Healthcare Professional provision; Both Emergency departments have responded to the Musculo-skeletal demand attending the departments by appointing Extended Scope Physiotherapists. YGC has also employed through seasonal plan funding GP support to ED to stream suitable patients away from the main emergency department pathways.”

Source location

2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017

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

Strengthen executive oversight of out-of-hours escalation and appoint a lead executive to engage with the Welsh Government Delivery Unit.

Verbatim wording from the response

“Engagement at an Executive Level I have taken steps to strengthen the level of visible Executive input to the management of escalation out-of-hours and nominated Morag Olsen as our lead Exec to link with the Welsh Government Delivery Unit to explore areas where further improvements.”

Source location

2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017

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 patient navigators at YGC Emergency Department to redirect and expedite care for walk-in attenders.

Verbatim wording from the response

“13. Patient Navigators at YGC Emergency Department; learning from Salford Hospital has been implemented at YGC through using patient navigators to help redirect and expedite patient care of walk in attenders.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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

Roll out treatment escalation plans for palliative and terminally ill patients across BCU.

Verbatim wording from the response

“14. Roll out of treatment escalation plans (TEP’s); a completed pilot of treatment escalation plans for palliative/terminally ill patients in Nursing and residential homes has resulted in a 50% reduction to referral to the emergency department and is now being rolled out across BCU.”

Source location

2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017

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

Increase emergency-department consultant presence through revised medical rotas at WMH and YGC.

Verbatim wording from the response

“The following are examples of operational decisions which have been influenced by the above information specifically in relation to improving performance at YGC and YMH:”

Source location

2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017

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