Heather Louise Parkhill · Prevention of Future Deaths report

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Issued 2 Feb 2026•North Wales (East and Central)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
26

Described in responses

Recipients and published responses

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. Unavailability of emergency ambulance resources
    Part of recurring concern: Insufficient ambulance service capacity for emergency calls
  2. Delays in emergency ambulance response times
    Part of recurring concern: Delays in ambulance attendance

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.26

  1. Premiere Health Limited

    Provide further mental-capacity and MCA training to all trained staff.

  2. Premiere Health Limited

    Conduct daily management checks of notes for residents declining personal care or presenting clinical concerns, with Team Leader cover during absence.

  3. Premiere Health Limited

    Disseminate admission and discharge-documentation learning to junior staff and provide supervision to staff responsible for admissions.

  4. Premiere Health Limited

    Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns, and hospital discharge.

  5. Premiere Health Limited

    Require nurses to act on escalated concerns and update care plans, supported by structured wound and infection monitoring charts with photographs.

  6. Premiere Health Limited

    Provide refresher training on record keeping, infection progression, infection recognition, wound documentation, sepsis awareness, and escalation.

  7. Premiere Health Limited

    Store policies centrally in a digital governance system accessible to all staff.

  8. Premiere Health Limited

    Implement immediate managerial review of incident forms to check detail, completeness, and clinical appropriateness.

  9. Premiere Health Limited

    Stop accepting residents requiring one-to-one support following review of acceptance criteria.

  10. Premiere Health Limited

    Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls and provide refresher training in incident reporting and falls management.

  11. Premiere Health Limited

    Establish a formal mental-capacity assessment procedure covering decision-specific capacity, care-plan outcomes, and best-interest documentation.

  12. Premiere Health Limited

    Implement a clinical escalation protocol requiring early medical review when symptoms do not improve.

  13. Premiere Health Limited

    Maintain governance oversight through clinical audits, supervision, competency checks, incident-trend monitoring, and senior management visits.

  14. Premiere Health Limited

    Implement a discharge-management system scanning summaries, reviewing them within 24 hours, logging actions, confirming follow-up with GPs, and auditing completion.

  15. Premiere Health Limited

    Strengthen falls and post-incident procedures requiring fall details, physical and neurological observations where indicated, pain assessment, and documented escalation reasoning.

  16. Premiere Health Limited

    Strengthen escalation to Adult Social Care through staff reminders, multidisciplinary reviews, mandatory placing-authority notification, and formal recording of communications.

  17. Welsh Ambulance Services NHS Trust

    Introduce purple and red emergency call categories for suspected cardiac or respiratory arrest and patients at high risk of arrest.

  18. Welsh Ambulance Services NHS Trust

    Increase ambulance resources by completing roster changes and improving attendance levels.

  19. Welsh Ambulance Services NHS Trust

    Offer more treatment at home or outside hospital in partnership with Health Board colleagues.

  20. Welsh Ambulance Services NHS Trust

    Implement the Welsh emergency ambulance performance framework to provide clinically driven, outcome-focused responses.

  21. Welsh Ambulance Services NHS Trust

    Increase remote clinical support to prioritise available resources and improve safety-netting during significant pressures.

  22. Welsh Ambulance Services NHS Trust

    Recruit 28 clinical advisers to support rapid 999-call screening and appropriate first responses.

  23. Welsh Ambulance Services NHS Trust

    Introduce an orange time-sensitive response category following clinical review of amber and green calls.

  24. Welsh Ambulance Services NHS Trust

    Apply rapid clinical screening to non-purple and non-red 999 calls to tailor responses to patient needs.

  25. Welsh Ambulance Services NHS Trust

    Test and evaluate the emergency response framework and its broader patient-outcome and experience measurements over 12 months.

  26. Welsh Ambulance Services NHS Trust

    Enhance staff knowledge, skills, competencies and available alternatives to minimise unnecessary hospital transport.

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 emergency ambulance resources

Wider context from the report

“Category of Concern – Emergency Services Related Death For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however problems regarding the unavailability of resources persist. I have a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue to be lost as a result of this problem. Despite all of the multi-agency efforts to improve the availability of resources and hence response times, nothing appears to change I therefore remain concerned that lives continue to be at risk ”

Is this part of a recurring concern?

Yes — 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 emergency ambulance response times

Wider context from the report

“Category of Concern – Emergency Services Related Death For many years, myself and other coroners have raised concerns regarding so called “ambulance delays” and I recognise that the challenges faced by WAST around the availability of resources are the result of multifactorial issues, however problems regarding the unavailability of resources persist. I have a mandatory statutory responsibility to raise concerns where they exist and it is clear that lives continue to be lost as a result of this problem. Despite all of the multi-agency efforts to improve the availability of resources and hence response times, nothing appears to change I therefore remain concerned that lives continue to be at risk ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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

Provide further mental-capacity and MCA training to all trained staff.

Verbatim wording from the response

“Actions implemented:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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 management checks of notes for residents declining personal care or presenting clinical concerns, with Team Leader cover during absence.

Verbatim wording from the response

“• The Care Manager now conducts daily checks on notes for residents who may be declining personal care or presenting clinical concerns.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 2 · response
Published 3 February 2026

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

Disseminate admission and discharge-documentation learning to junior staff and provide supervision to staff responsible for admissions.

Verbatim wording from the response

“• All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case, ensuring learning is embedded.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 1 · response
Published 3 February 2026

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

Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns, and hospital discharge.

Verbatim wording from the response

“Actions taken:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 4 · response
Published 3 February 2026

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

Require nurses to act on escalated concerns and update care plans, supported by structured wound and infection monitoring charts with photographs.

Verbatim wording from the response

“• Registered Nurses are required to take action on concerns escalated to them and update care plans accordingly.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 2 · response
Published 3 February 2026

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

Provide refresher training on record keeping, infection progression, infection recognition, wound documentation, sepsis awareness, and escalation.

Verbatim wording from the response

“• Staff have received feedback on the importance of record keeping, particularly where care is refused.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 2 · response
Published 3 February 2026

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

Store policies centrally in a digital governance system accessible to all staff.

Verbatim wording from the response

“• Policies are now centrally stored within a digital governance system, accessible to all staff.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 4 · response
Published 3 February 2026

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 immediate managerial review of incident forms to check detail, completeness, and clinical appropriateness.

Verbatim wording from the response

“• All staff have been reminded of the established incident procedure.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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

Stop accepting residents requiring one-to-one support following review of acceptance criteria.

Verbatim wording from the response

“Actions taken include:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 2 · response
Published 3 February 2026

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

Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls and provide refresher training in incident reporting and falls management.

Verbatim wording from the response

“• Mandatory post-fall observation charts are now used for unwitnessed or potentially injurious falls.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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 formal mental-capacity assessment procedure covering decision-specific capacity, care-plan outcomes, and best-interest documentation.

Verbatim wording from the response

“• A formal Mental Capacity Assessment Procedure is now in place requiring:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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 a clinical escalation protocol requiring early medical review when symptoms do not improve.

Verbatim wording from the response

“• A consolidated clinical escalation protocol is being implemented, requiring early medical review where symptoms do not improve.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 2 · response
Published 3 February 2026

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

Maintain governance oversight through clinical audits, supervision, competency checks, incident-trend monitoring, and senior management visits.

Verbatim wording from the response

“• Regular audits are undertaken to ensure compliance.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 4 · response
Published 3 February 2026

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 a discharge-management system scanning summaries, reviewing them within 24 hours, logging actions, confirming follow-up with GPs, and auditing completion.

Verbatim wording from the response

“Following the inquest, the following actions have been implemented:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 1 · response
Published 3 February 2026

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 falls and post-incident procedures requiring fall details, physical and neurological observations where indicated, pain assessment, and documented escalation reasoning.

Verbatim wording from the response

“• A strengthened Falls Management and Post-Incident Observation Procedures in place, including:”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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 escalation to Adult Social Care through staff reminders, multidisciplinary reviews, mandatory placing-authority notification, and formal recording of communications.

Verbatim wording from the response

“• All staff have been reminded of the importance of documenting and communicating concerns to Social Workers and Adult Social Care, both at admission and throughout residency.”

Source location

2026-0050 - Response from Premiere Health Ltd
Page 3 · response
Published 3 February 2026

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

Introduce purple and red emergency call categories for suspected cardiac or respiratory arrest and patients at high risk of arrest.

Verbatim wording from the response

“Two new categories of call were initially introduced in July – a new purple category for people suffering a suspected cardiac and respiratory arrest and the red category for people at high risk of cardiac and respiratory arrest, including where this is a result of injury or illness.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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 ambulance resources by completing roster changes and improving attendance levels.

Verbatim wording from the response

“The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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

Offer more treatment at home or outside hospital in partnership with Health Board colleagues.

Verbatim wording from the response

“The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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 Welsh emergency ambulance performance framework to provide clinically driven, outcome-focused responses.

Verbatim wording from the response

“In July 2025, a new emergency ambulance performance framework was introduced in Wales, supporting a move away from time-based targets towards a more clinically driven, outcome-focused approach, with an emphasis on responding quickly to people with time-sensitive conditions.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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 remote clinical support to prioritise available resources and improve safety-netting during significant pressures.

Verbatim wording from the response

“The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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

Recruit 28 clinical advisers to support rapid 999-call screening and appropriate first responses.

Verbatim wording from the response

“As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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

Introduce an orange time-sensitive response category following clinical review of amber and green calls.

Verbatim wording from the response

“The next phase of the framework was introduced in December, following a clinical review of the amber and green categories of call. A new orange – time-sensitive response category was introduced. This was designed to ensure people with conditions such as suspected stroke or STEMI are identified earlier through enhanced clinical screening in the 999 contact centres to receive a faster, more appropriate ambulance response, and rapid transport to specialist care.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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

Apply rapid clinical screening to non-purple and non-red 999 calls to tailor responses to patient needs.

Verbatim wording from the response

“As part of the framework, all 999 calls to WAST, which are not classified as either purple or red, go through rapid clinical screening to ensure everyone receives a more tailored approach. This means the ambulance service takes account of their symptoms and where the incident occurred to determine what sort of response they receive. Every person receives a tailored response but not everyone will need an ambulance – they may receive a different clinical response, which is appropriate to their needs. An additional 28 clinical advisers – new posts – were recruited to support this new process to ensure people get the right response the first time.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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

Test and evaluate the emergency response framework and its broader patient-outcome and experience measurements over 12 months.

Verbatim wording from the response

“The new framework also increases opportunities to better understand patient outcomes and experience by broadening measurement beyond initial response times to include more clinically meaningful metrics, such as call-to-door times. The intent is to enable clearer insight into the timeliness and quality of care delivered to patients with serious and time-sensitive conditions, including stroke, to drive quality improvement.”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 3 · response
Published 3 February 2026

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

Enhance staff knowledge, skills, competencies and available alternatives to minimise unnecessary hospital transport.

Verbatim wording from the response

“The concern you express about the continued impact and harm resulting from extensive community waits for ambulances is shared by myself, the Executive team and our Trust Board at WAST. Over the years, the Trust has shared with you all the measures that have been taken in an attempt to manage and address the changes in the pressures both within the Trust and across the wider NHS Wales landscape. These actions include:”

Source location

2026-0050 - Response from Welsh Ambulance Services University NHS Trust
Page 2 · response
Published 3 February 2026

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