PFD report

Raymond Gillespie · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 25 May 2022•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
3

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Risk of deaths associated with delayed ambulance transfer or unavailability
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Delays in ambulance-to-hospital patient handoverPart of recurring concern: Insufficient ambulance service capacity for emergency calls
  2. Failure to make ambulance resources available for lower-priority or later-registered calls
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
  3. Delays in ambulance handovers across BCUHB sites
    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.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Risk of deaths associated with delayed ambulance transfer or unavailability

Wider context from the report

“(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call (2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021. (3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital. (4) The matters of concern herein are longstanding and despite proposed future action the concerns remain. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Delays in ambulance-to-hospital patient handover; Insufficient ambulance service capacity for emergency calls.

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

Failure to make ambulance resources available for lower-priority or later-registered calls

Wider context from the report

“(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call (2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021. (3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital. (4) The matters of concern herein are longstanding and despite proposed future action the concerns remain. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Insufficient ambulance service capacity for emergency calls.

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 ambulance handovers across BCUHB sites

Wider context from the report

“(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call (2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021. (3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital. (4) The matters of concern herein are longstanding and despite proposed future action the concerns remain. ”

Is this part of a recurring concern?

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

Open source report
Back to top

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