PFD report

Christopher George Connor · Prevention of Future Deaths report

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Issued 12 Nov 2015•Powys, Bridgend and Glamorgan Valleys

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
1

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
1

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 raised1

  1. Delays in ambulance attendance
    Part of recurring concern: Delays in ambulance attendance
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.1

  1. Action

    Provide additional education and support to all call takers involved in the incident.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.

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

  1. Position

    The ambulance was allocated one minute before South Wales Police contacted the control centre, rather than after police expedited the call.

    Stated by Welsh Ambulance Services NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 attendance

Wider context from the report

“(1) The delay in the attendance of an ambulance which, on the evidence, only arrived after police officers arrived on the scene and “expedited” the call to the ambulance control room. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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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 additional education and support to all call takers involved in the incident.

Verbatim wording from the response

“The investigation determined that the root cause of the failings emanated from one individual member of staff. Specifically the Clinical Contact Centre Allocator and I can confirm that the Trust has acted upon these findings in relation to that individual who is currently being managed in line with the Trust’s relevant policies and procedures regarding the failings identified. I can assure you that the Trust views matters of this nature extremely seriously and in addition to the above, all the call takers involved in this incident have also received additional education and support.”

Source location

2016-0461-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 November 2015

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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

The ambulance was allocated one minute before South Wales Police contacted the control centre, rather than after police expedited the call.

Verbatim wording from the response

“One minute after allocation of this vehicle, a third call was received in relation to this incident from South Wales Police informing our Clinical Contact Centre that they had received a call for this patient. The Trust call taker who had remained in contact with the caller identified that a police officer arrived at the scene at approximately 02:00hrs.”

Source location

2016-0461-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 November 2015

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