PFD report

Gladys May Williams · Prevention of Future Deaths report

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Issued 10 Sep 2018•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
4

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.

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Concerns and recipient responses

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

Concerns raised4

  1. Failure to provide timely admission to the emergency department
    Part of recurring concern: Failure to provide timely hospital admission
  2. Failure of patient flow processes
    Part of recurring concern: Failure to maintain safe hospital patient flow
  3. Unavailability of required resources
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

Failure to provide timely admission to the emergency department

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position. ”

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

Failure of patient flow processes

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe hospital patient flow.

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

Unavailability of required resources

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 response or transfer

Wider context from the report

“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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