PFD report

Jeffrey Martin Tyler · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 18 Feb 2025•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.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

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 raised2

  1. Failure to revise ambulance priority when a patient is deteriorating and in extremis
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deteriorationPart of recurring concern: Unreliable ambulance call triage and re-triagePart of recurring concern: Unreliable ambulance response-time standards and prioritisation
  2. Inability of a patient who is alone to inform the ambulance service of deterioration
    Part of recurring concern: Unsafe management of ambulance calls involving callers who are alone
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

    Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
  2. Action

    Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
  3. Action

    Establish a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.

    Stated by Welsh GovernmentOutside remitThe respondent said that this matter was outside its role or authority.

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 revise ambulance priority when a patient is deteriorating and in extremis

Wider context from the report

“In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated. Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unreliable ambulance call triage and re-triage; Unreliable ambulance response-time standards and prioritisation.

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

Inability of a patient who is alone to inform the ambulance service of deterioration

Wider context from the report

“In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated. Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours. ”

Is this part of a recurring concern?

Yes — Unsafe management of ambulance calls involving callers who are alone.

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

Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.

Verbatim wording from the response

“I hold the Chair of WAST to account for oversight of the delivery of those expectations through regular meetings. Officials also hold the Chief Executive Officer and his executive team to account through bimonthly integrated quality planning and delivery (IQPD) meetings where progress against key performance targets is scrutinised and assurance on the quality and safety of services is sought. I have asked officials to seek assurance on the process of categorisation of calls and steps taken by the Trust to ensure service users receive the right response for their clinical need at the next IQPD meeting to be held on 24 April 2025.”

Source location

Response from Welsh Government
Page 2 · response
Published 20 February 2025

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

Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.

Verbatim wording from the response

“Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.”

Source location

Response from Welsh Government
Page 3 · response
Published 20 February 2025

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 a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.

Verbatim wording from the response

“Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.”

Source location

Response from Welsh Government
Page 3 · response
Published 20 February 2025

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

Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.

Verbatim wording from the response

“However, it is important to note, that the Welsh Ministers are not responsible for the delivery of health services in Wales. Instead, Local Health Boards (LHBs) are responsible for planning, commissioning and delivering services for the population of its area and NHS Trusts are responsible for the delivery of services across Wales within the national policy framework set by the Welsh Ministers.”

Source location

Response from Welsh Government
Page 1 · response
Published 20 February 2025

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

WAST is responsible for operational emergency ambulance call categorisation and is best placed to respond to required action.

Verbatim wording from the response

“The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 establishes the Welsh Ambulance Services University National Health Service Trust (WAST). Article 3 delegates the function of managing the ambulance service to WAST.”

Source location

Response from Welsh Government
Page 2 · response
Published 20 February 2025

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.2

  1. 1

    Implement the new Emergency Ambulance Performance Framework, including increased focus on clinical outcomes.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
  2. 2

    Establish and complete an Ambulance Response Target Review of the red ambulance response target.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.

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 new Emergency Ambulance Performance Framework, including increased focus on clinical outcomes.

Verbatim wording from the response

“Following agreement of recommendations from the group, on 11 March 2025, I announced via an Oral Statement the implementation of a new Emergency Ambulance Performance Framework (Appendix 1). This has increased focus on clinical outcomes – especially following an out of hospital cardiac arrest – and will be implemented from 1 July 2025.”

Source location

Response from Welsh Government
Page 2 · response
Published 20 February 2025

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 complete an Ambulance Response Target Review of the red ambulance response target.

Verbatim wording from the response

“In November 2024, I established an Ambulance Response Target Review in response to a recommendation made by the Health and Social Care Committee to review the current ‘red’ ambulance response target. The task group was predominantly made up of clinical experts in the field of pre-hospital emergency care and ambulance response.”

Source location

Response from Welsh Government
Page 2 · response
Published 20 February 2025

Open published response
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