PFD report

Sarah Ann Tyler · Prevention of Future Deaths report

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Issued 13 Jan 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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised2

  1. Insufficient hospital bed capacity causing delays in admissions
    Part of recurring concern: Failure to provide timely hospital admission
  2. Insufficient weekend hospital discharges contributing to bed blocking
    Part of recurring concern: Unreliable hospital discharge processes
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.3

  1. Action

    Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  2. Action

    Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  3. Action

    Provide joint community and hospital services to avoid admissions where patients can safely be cared for at home.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

  1. Position

    Without wholesale changes to working practices, differences in hospital operations between Sundays and other days will continue.

    Stated by Betsi Cadwaladr University LHBUnable 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

Insufficient hospital bed capacity causing delays in admissions

Wider context from the report

“1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions. 2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital. ”

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

Insufficient weekend hospital discharges contributing to bed blocking

Wider context from the report

“1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions. 2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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

Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.

Verbatim wording from the response

“Whilst the majority of patients are treated or admitted within the acceptable time, a significant minority took longer to be treated or admitted and a proportion of these will have waited significantly longer. The Health Board is required by Welsh Government to have a plan in place so that performance against the 4 hour target is improved, and that more patients are treated or admitted within 4 hours. The plan to achieve this improvement is set out in the Health Board’s plan for Unscheduled Care Plan, which is a chapter within the overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached in appendix 1. (The plan is a draft at this stage pending feedback on the draft from Welsh Government).”

Source location

2017-0002-Response-by-University-Health-Board
Page 1 · response
Published 19 February 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

Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.

Verbatim wording from the response

“Reducing Length of Stay In addition to the work to reduce admissions, there is also a significant focus on reducing the time spent in hospital for patients that are admitted. Patients who experience a Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a support package to be provided in their own home. The Health Board carried out a detailed joint assessment of the issues that cause delay in December 2016 jointly with Local Authorities and the Independent Sector providers of care services (care home and home care). The plans to reduce DTOCs and length of stay are set out in the plan.”

Source location

2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 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

Provide joint community and hospital services to avoid admissions where patients can safely be cared for at home.

Verbatim wording from the response

“Admission Avoidance Patients attend ED as a method of gaining access to health services. The Unscheduled Care plan sets out the overall approach to ensuring that wherever possible, patients can be treated without requiring admission to a hospital bed. The plan describes how community services and hospital services will be provided jointly so that patients will be provided with the same community services, irrespective of whether they present to our services through the GP or via the Emergency Department. For example, if a patient who is already known to community services attends ED, the District Nursing team are automatically informed and will attend to review if the patient can be cared for at home.”

Source location

2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017

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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

Without wholesale changes to working practices, differences in hospital operations between Sundays and other days will continue.

Verbatim wording from the response

“Bed availability at weekends The Health Board does also ensure that doctors and discharge teams are available to support at weekends but, in the absence of a whole scale change in working practices, there will continue to be differences in the way that the hospital operates on a Sunday compared to other days in the week.”

Source location

2017-0002-Response-by-University-Health-Board
Page 3 · response
Published 19 February 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.4

  1. 1

    Continue reviewing the ambulance-waiting process to minimise inconvenience and eliminate harm.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  2. 2

    Oversee Unscheduled Care Plan implementation through a Health Board-wide transformation group and local implementation groups, with monthly progress updates and Welsh Government monitoring.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  3. 3

    Assess ambulance patients promptly on arrival and every 30 minutes, prioritising clinically unstable patients for departmental transfer and offering waiting refreshments.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  4. 4

    Conduct daily retrospective reviews of patients waiting in ambulances for more than one hour.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 February 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

Continue reviewing the ambulance-waiting process to minimise inconvenience and eliminate harm.

Verbatim wording from the response

“We do recognise that it is unsatisfactory for any patient to wait for admission and do undertake to assess every patient waiting in an ambulance as soon as possible after arrival and at 30 minute intervals thereafter. This triage assessment is undertaken by a skilled triage nurse and at times by an emergency department doctor. Where clinically required we will prioritise the sickest or most unstable patients for transfer into the department and ensure that patients and those with them are offered refreshments while they are waiting. We also undertake a daily retrospective review of all patients who have waited in an ambulance for longer than an hour. We continue to review this process in order to minimise the inconvenience and eliminate harm.”

Source location

2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 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

Oversee Unscheduled Care Plan implementation through a Health Board-wide transformation group and local implementation groups, with monthly progress updates and Welsh Government monitoring.

Verbatim wording from the response

“The Unscheduled Care Plan sets out the targets set by the Health Board in each section of the plan and the whole of the plan will be implemented within 2017/8. The implementation of the plan will be overseen by the Health Board wide Unscheduled Care Transformation Group, which is supported by local implementation groups and projects charged with delivering each element of the plan. There will be monthly updates within the Health Board on the progress of the plan and progress against the plan will be monitored by Welsh Government.”

Source location

2017-0002-Response-by-University-Health-Board
Page 3 · response
Published 19 February 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

Assess ambulance patients promptly on arrival and every 30 minutes, prioritising clinically unstable patients for departmental transfer and offering waiting refreshments.

Verbatim wording from the response

“We do recognise that it is unsatisfactory for any patient to wait for admission and do undertake to assess every patient waiting in an ambulance as soon as possible after arrival and at 30 minute intervals thereafter. This triage assessment is undertaken by a skilled triage nurse and at times by an emergency department doctor. Where clinically required we will prioritise the sickest or most unstable patients for transfer into the department and ensure that patients and those with them are offered refreshments while they are waiting. We also undertake a daily retrospective review of all patients who have waited in an ambulance for longer than an hour. We continue to review this process in order to minimise the inconvenience and eliminate harm.”

Source location

2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 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

Conduct daily retrospective reviews of patients waiting in ambulances for more than one hour.

Verbatim wording from the response

“We do recognise that it is unsatisfactory for any patient to wait for admission and do undertake to assess every patient waiting in an ambulance as soon as possible after arrival and at 30 minute intervals thereafter. This triage assessment is undertaken by a skilled triage nurse and at times by an emergency department doctor. Where clinically required we will prioritise the sickest or most unstable patients for transfer into the department and ensure that patients and those with them are offered refreshments while they are waiting. We also undertake a daily retrospective review of all patients who have waited in an ambulance for longer than an hour. We continue to review this process in order to minimise the inconvenience and eliminate harm.”

Source location

2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 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