PFD report

Joseph Leonard Scott Cattle · Prevention of Future Deaths report

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Issued 22 Feb 2024•South Wales 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
14

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 hospital handover holding up ambulance resources
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
  2. Delays in allocating available ambulance resources to Amber 1 calls
    Part of recurring concern: Unreliable ambulance dispatch and resource-allocation controls
  3. Insufficient funded ambulance capacity
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

    Direct each Local Health Board to develop a local Six Goals plan incorporating ambulance handover and patient-flow improvements.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  2. Action

    Monitor and scrutinise Local Health Board and ambulance-service performance against ambulance handover targets through regular assurance meetings and escalation arrangements.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
  3. Action

    Issue guidance setting expectations and targets for timely ambulance handover, including required actions when handover exceeds 60 minutes.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.

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

  1. Position

    The NHS Joint Commissioning Committee is responsible for determining the funding allocated to WAST for emergency ambulance services.

    Stated by Welsh GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 hospital handover holding up ambulance resources

Wider context from the report

“(2) Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals; ”

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

Delays in allocating available ambulance resources to Amber 1 calls

Wider context from the report

“(1) Welsh Ambulance Service Trust were unable to allocate an available ambulance resource in an Amber 1 category call until over 6 hours from the time of the 999 call; ”

Is this part of a recurring concern?

Yes — Unreliable ambulance dispatch and resource-allocation controls.

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

Insufficient funded ambulance capacity

Wider context from the report

“(3) The number of funded ambulances appeared to be significantly short of what would have been needed in the circumstances. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Direct each Local Health Board to develop a local Six Goals plan incorporating ambulance handover and patient-flow improvements.

Verbatim wording from the response

“I have directed each LHB to develop a local ‘six goals’ programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. This programme plan forms a key part of LHBs’ broader Integrated Medium-Term Plans (IMTPs).”

Source location

Response from Welsh Government
Page 2 · response
Published 26 February 2024

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 and scrutinise Local Health Board and ambulance-service performance against ambulance handover targets through regular assurance meetings and escalation arrangements.

Verbatim wording from the response

“In practice, the Welsh Government monitors the performance of NHS Wales bodies in several different ways. In relation to the monitoring of ambulance patient handovers to emergency departments, a number of specific measures have been put in place in order to ensure the Welsh Government can assess how LHBs and WAST are performing.”

Source location

Response from Welsh Government
Page 4 · response
Published 26 February 2024

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

Issue guidance setting expectations and targets for timely ambulance handover, including required actions when handover exceeds 60 minutes.

Verbatim wording from the response

“A Welsh Health Circular (“WHC”) was issued in 2016, setting out expectations of LHBs and partners to deliver timely ambulance patient handover through consistent delivery of a range of actions for both pre and post arrival such as: communication, alternative pathways, staffing levels, and booking in processes. It is the expectation of the Welsh Government that these actions are done consistently to meet handover targets.”

Source location

Response from Welsh Government
Page 4 · response
Published 26 February 2024

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 the Pathways of Care Delays Reporting Framework to provide regional data for targeting discharge interventions.

Verbatim wording from the response

“To ensure we have accurate data on delayed discharges, the Pathways of Care Delays (PoCD) Reporting Framework has been implemented. This is a formal reporting mechanism that provides health and social care partners with a comprehensive and vital overview of their regional discharge delays so that relevant interventions and actions can be targeted more appropriately.”

Source location

Response from Welsh Government
Page 4 · response
Published 26 February 2024

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 the NHS Joint Commissioning Committee chair accountable for effective emergency-ambulance commissioning and achievement of ministerial priorities.

Verbatim wording from the response

“These commissioning arrangements were reviewed in 2022-23 as part of a wider independent review of national commissioning of NHS services in Wales. That review recommended establishing a new joint committee of LHBs to hold responsibility for commissioning of specialised services and emergency ambulance services among others. The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services.”

Source location

Response from Welsh Government
Page 6 · response
Published 26 February 2024

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

The NHS Joint Commissioning Committee is responsible for determining the funding allocated to WAST for emergency ambulance services.

Verbatim wording from the response

“These commissioning arrangements were reviewed in 2022-23 as part of a wider independent review of national commissioning of NHS services in Wales. That review recommended establishing a new joint committee of LHBs to hold responsibility for commissioning of specialised services and emergency ambulance services among others. The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services.”

Source location

Response from Welsh Government
Page 6 · response
Published 26 February 2024

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

    Continue working through the Social Care Fair Work Forum to improve social-care terms, conditions and workforce attractiveness.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
  2. 2

    Continue investing in the WeCare.Wales social-care recruitment campaign.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
  3. 3

    Work with the NHS Executive and ambulance commissioners to develop focused care pathways reducing conveyance and enabling direct access for time-critical conditions.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  4. 4

    Publish updated Hospital Discharge Guidance covering safe, timely discharge and patient-transport support.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  5. 5

    Fund social-care workforce measures, including real-living-wage support and the Workforce and Sustainable Social Services grant.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  6. 6

    Increase the annual Six Goals programme allocation to £27 million in 2024/2025.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  7. 7

    Review WAST vehicle-replacement business cases and decide on proposed capital funding.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  8. 8

    Establish and fund the Six Goals for Urgent and Emergency Care national improvement programme.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  9. 9

    Publish the Quality Statement for Care in Emergency Departments.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.

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 working through the Social Care Fair Work Forum to improve social-care terms, conditions and workforce attractiveness.

Verbatim wording from the response

“Welsh Government acknowledges the challenges facing our social care workforce and the need to attract more care workers into the sector to support the work around community discharge and patient flow. Social care is competing with sectors such as retail and hospitality in terms of pay which are offering more pay for less intensive roles, therefore the option for progression and the ability to build a career in social care is our priority. We are committed to raising the profile and status of the workforce through registration of the workforce, promoting and improving pay, terms and conditions, through the work of the Social Care Fair Work Forum.”

Source location

Response from Welsh Government
Page 3 · response
Published 26 February 2024

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 investing in the WeCare.Wales social-care recruitment campaign.

Verbatim wording from the response

“We are moving in to the third financial year of our Programme for Government commitment to pay the real living wage to social care workers in Wales, providing funding circa £113 million across 2022-23 and 2023-24 to support this commitment. In 2024-25, the then Minister for Finance and Local Government confirmed funding within the Local Government’s Revenue Support Grant (RSG) to meet the costs of the Real Living Wage of £12 an hour for social care workers alongside recurrent funding to the sector in the form of a £45 million Workforce and Sustainable Social Services grant, to support a range of workforce interventions, including further salary uplifts and to support additional staffing in some areas. We also continue to invest in Social Care Wales recruitment campaign, ‘WeCare.Wales’, which promotes the variety of roles available in Social Care.”

Source location

Response from Welsh Government
Page 3 · response
Published 26 February 2024

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 the NHS Executive and ambulance commissioners to develop focused care pathways reducing conveyance and enabling direct access for time-critical conditions.

Verbatim wording from the response

“Welsh Government officials are currently working with the NHS Executive and ambulance commissioners to consider additional focused plans to enable consistent delivery of condition specific pathways that will support better care of frail / older people without the need for conveyance to emergency departments. These plans will also enable action to support people with time critical complaints e.g. stroke and / or STEMI (a type of”

Source location

Response from Welsh Government
Page 2 · response
Published 26 February 2024

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

Publish updated Hospital Discharge Guidance covering safe, timely discharge and patient-transport support.

Verbatim wording from the response

“Hospital discharge guidance”

Source location

Response from Welsh Government
Page 3 · response
Published 26 February 2024

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

Fund social-care workforce measures, including real-living-wage support and the Workforce and Sustainable Social Services grant.

Verbatim wording from the response

“We are moving in to the third financial year of our Programme for Government commitment to pay the real living wage to social care workers in Wales, providing funding circa £113 million across 2022-23 and 2023-24 to support this commitment. In 2024-25, the then Minister for Finance and Local Government confirmed funding within the Local Government’s Revenue Support Grant (RSG) to meet the costs of the Real Living Wage of £12 an hour for social care workers alongside recurrent funding to the sector in the form of a £45 million Workforce and Sustainable Social Services grant, to support a range of workforce interventions, including further salary uplifts and to support additional staffing in some areas. We also continue to invest in Social Care Wales recruitment campaign, ‘WeCare.Wales’, which promotes the variety of roles available in Social Care.”

Source location

Response from Welsh Government
Page 3 · response
Published 26 February 2024

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 the annual Six Goals programme allocation to £27 million in 2024/2025.

Verbatim wording from the response

“We established a national improvement programme (the ‘Six Goals for Urgent and Emergency Care programme’) to enable LHBs to deliver on the objectives set out in our strategy, and have allocated an additional £50m in support over the past two years. The annual Six Goals allocation will increase to £27m in 2024/2025.”

Source location

Response from Welsh Government
Page 2 · response
Published 26 February 2024

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 WAST vehicle-replacement business cases and decide on proposed capital funding.

Verbatim wording from the response

“In terms of procuring ambulance vehicles, WAST submitted a Strategic Outline Programme (SOP) in 2016 that was endorsed by Welsh Cabinet Secretaries for its Vehicle Replacement Programme. The endorsement of the SOP allows WAST to submit Business Justification Cases (BJCs) setting out its vehicle replacement requirements on an annual basis. I will then make a decision on the BJ. Capital funding over the last three years is as follows:-”

Source location

Response from Welsh Government
Page 6 · response
Published 26 February 2024

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 and fund the Six Goals for Urgent and Emergency Care national improvement programme.

Verbatim wording from the response

“We established a national improvement programme (the ‘Six Goals for Urgent and Emergency Care programme’) to enable LHBs to deliver on the objectives set out in our strategy, and have allocated an additional £50m in support over the past two years. The annual Six Goals allocation will increase to £27m in 2024/2025.”

Source location

Response from Welsh Government
Page 2 · response
Published 26 February 2024

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

Publish the Quality Statement for Care in Emergency Departments.

Verbatim wording from the response

“Quality statement for care in ED”

Source location

Response from Welsh Government
Page 3 · response
Published 26 February 2024

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