PFD report

Andres Roberts · Prevention of Future Deaths report

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Issued 23 Sep 2020•Swansea and Neath Port Talbot

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
2

Of 2 recipients

Stated actions
18

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 raised3

  1. Insufficient WAST resources to meet stroke response targets
  2. Lack of a specific time target for stroke care
  3. Inappropriate grading of stroke patients falling in the amber category
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.5

  1. Action

    Implement capacity-and-demand review recommendations, including recruiting 136 full-time-equivalent frontline staff during 2020/21.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  2. Action

    Implement the Clinical Response Model, including removal of timed targets except for immediately life-threatening conditions.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  3. Action

    Introduce additional paramedics, emergency medical technicians and urgent care staff to increase roster relief capacity and ambulance provision.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Clinical prioritisation is preferred to universal ambulance response-time targets because time-based targets may drive perverse and inefficient interventions.

    Stated by Welsh GovernmentDisputes 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

Insufficient WAST resources to meet stroke response targets

Wider context from the report

“(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment" (2) My concerns centre on :- A) the appropriateness of the grading of stroke patients falling in the amber category and B) whether a specific time target should be set and C) whether additional resources should be made available to WAST to meet these targets ”

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

Lack of a specific time target for stroke care

Wider context from the report

“(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment" (2) My concerns centre on :- A) the appropriateness of the grading of stroke patients falling in the amber category and B) whether a specific time target should be set and C) whether additional resources should be made available to WAST to meet these targets ”

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

Inappropriate grading of stroke patients falling in the amber category

Wider context from the report

“(1) In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact likelihood of a different outcome as "he did have a big stroke to begin with and each patient reacts differently to the treatment" (2) My concerns centre on :- A) the appropriateness of the grading of stroke patients falling in the amber category and B) whether a specific time target should be set and C) whether additional resources should be made available to WAST to meet these targets ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement capacity-and-demand review recommendations, including recruiting 136 full-time-equivalent frontline staff during 2020/21.

Verbatim wording from the response

“I note your concerns regarding resources available to enable WAST to respond to calls in a timely manner. The Trust is currently implementing the recommendations of an independent capacity and demand review, which will see 136 FTE staff recruited in 2020/21, significantly increasing the number of frontline staff available across the service to respond to incidents. This should support an improvement in responsiveness, although the wider health and care system also has a role to play in enabling improved patient flow through the hospital system and out into the community. This should reduce ambulance patient handover delays and unlock more capacity to respond quickly. A range of actions are also underway to better manage patient demand in the community to help prevent avoidable transport of patients to hospital.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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 Clinical Response Model, including removal of timed targets except for immediately life-threatening conditions.

Verbatim wording from the response

“Each ambulance service has a response model that supports the categorisation given to each call (irrespective of which prioritisation system is used). That response model and the decisions made will reflect the demographics of the population and the geography being served by that individual ambulance service. In 2015 the Welsh Ambulance Services NHS Trust introduced its current Clinical Response Model (the Model), which removed timed targets for all but those patients with immediately life-threatening illnesses or injuries. The Model underwent a trial period before being approved by the Welsh Government and fully implemented by the Trust.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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 additional paramedics, emergency medical technicians and urgent care staff to increase roster relief capacity and ambulance provision.

Verbatim wording from the response

“In relation to whether additional resources should be made available to the Trust to meet these targets, the Trust has undertaken a Demand and Capacity review, which has identified the need for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority of these additional staff will be introduced over the next 4 years to increase the relief capacity within the current rosters, allowing for increased ambulance provision to meet demand.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Expand clinical desk staffing in the 999 control room to support timely assessment and appropriate resource allocation.

Verbatim wording from the response

“• We have expanded our clinicians on the clinical desk in our 999 control room to support timely clinical assessment and to ensure we are sending the appropriate resource to the individual patient.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 4 · response
Published 19 November 2020

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 a Demand and Capacity review to identify additional staffing requirements across Wales.

Verbatim wording from the response

“In relation to whether additional resources should be made available to the Trust to meet these targets, the Trust has undertaken a Demand and Capacity review, which has identified the need for a number of additional Paramedics, EMT’s and Urgent Care Staff across Wales. The majority of these additional staff will be introduced over the next 4 years to increase the relief capacity within the current rosters, allowing for increased ambulance provision to meet demand.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Clinical prioritisation is preferred to universal ambulance response-time targets because time-based targets may drive perverse and inefficient interventions.

Verbatim wording from the response

“As part of the introduction of the clinical response model in Wales in October 2015, time-based targets were removed for all but the highest priority immediately life-threatening or ‘Red’ calls. This decision was made on the basis of clinical evidence that a higher proportion of patients in most need of an immediate intervention would receive a faster response to optimise their outcomes.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 1 · response
Published 19 November 2020

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

No specific response-time target is considered necessary because clinically important timing runs from symptom onset to hospital arrival.

Verbatim wording from the response

“Following receipt of the Regulation 28, and consideration of the facts within, I would sincerely appreciate the opportunity to discuss these with you, as the Trust does not propose, at this time, to take any action in relation to the three matters you have raised. The reasons for which I will explain below.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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

The principal issue is not stroke-call categorisation; prioritisation by clinical severity is considered appropriate.

Verbatim wording from the response

“In closing, I am of the view that the principle issue for us here is not one of categorisation as it is right to have a system of priority that assigns more rapidly to clinical severity.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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.13

  1. 1

    Provide £30 million of additional funding to transform urgent and emergency care services and increase resilience during 2020/21.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  2. 2

    Deliver urgent and emergency care interventions and operational plans with partners to direct patients to appropriate advice, assessment and treatment settings.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.
  3. 3

    Maintain mandatory clinical guidance ensuring suspected stroke patients reach appropriate settings within agreed clinical guidelines.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  4. 4

    Resume and expedite the Ministerial Ambulance Availability Taskforce work programme, including submitting an interim report by the end of December 2020.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  5. 5

    Implement community demand-management actions to reduce avoidable ambulance transport to hospital.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  6. 6

    Develop and consult on broader ambulance quality measures for stroke response times, for publication in the New Year.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  7. 7

    Implement outstanding recommendations from the all-Wales thrombolysis review with WAST and Health Boards.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  8. 8

    Develop a Demand Management Plan to coordinate service actions during periods of escalated pressure.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  9. 9

    Continue working with Health Boards across Wales to address ambulance delays at hospitals.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  10. 10

    Support out-of-hours patient discharge and transfer to release hospital beds and improve emergency department flow.

    Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  11. 11

    Continue recruiting and training Advanced Paramedic Practitioners to treat patients at home where possible.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  12. 12

    Operate the Operational Delivery Unit as a leadership and coordination hub to monitor demand, manage hospital delays and mitigate risks to patient care.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  13. 13

    Develop out-of-hospital pathways with Health Boards to safely reduce hospital conveyance.

    Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.

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 £30 million of additional funding to transform urgent and emergency care services and increase resilience during 2020/21.

Verbatim wording from the response

“We have also made £30m additional funding available to enable transformation of urgent and emergency care services and increase resilience over the remainder of 2020/21, including four priorities to optimise patient flow, experience, outcome and value when people access urgent and emergency care services:”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Deliver urgent and emergency care interventions and operational plans with partners to direct patients to appropriate advice, assessment and treatment settings.

Verbatim wording from the response

“1. Co-ordination, planning and support for high risk groups - Planning and support to help high risk or vulnerable people and their carers to remain independent at home, preventing the need for urgent care”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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 mandatory clinical guidance ensuring suspected stroke patients reach appropriate settings within agreed clinical guidelines.

Verbatim wording from the response

“The Welsh Government and the Welsh Ambulance Services Trust (WAST) recognise the importance of providing a safe and timely ambulance response to suspected stroke patients, as a key part of their patient journey. The Trust aims to respond to patients with new onset stroke as quickly as possible by dispatching a suitable emergency ambulance vehicle under blue light driving conditions, which is capable of transporting the patient immediately to a specialist stroke team to begin the treatment they require. The Trust has also put in place strong clinical guidance that must be followed for all suspected stroke patients, which ensures that actual and potential stroke patients are transferred to the appropriate settings within the clinically agreed guidelines.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 1 · response
Published 19 November 2020

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

Resume and expedite the Ministerial Ambulance Availability Taskforce work programme, including submitting an interim report by the end of December 2020.

Verbatim wording from the response

“You may also wish to be aware that a Ministerial Ambulance Availability Taskforce has been established to focus on ambulance responsiveness and the need for wider whole-system improvements to reflect and respond to the changing environment in which ambulance services are delivered. This includes the changing picture of demand and performance for immediately life-threatening (Red) calls, ambulance patient handover delays and the wider health and social care landscape. The taskforce will have a key role to play in delivering a more effective ambulance response and while it was temporarily stood down to enable a focus on response to Covid-19, its work programme has been resumed and will be expedited, with a view to submitting its interim report to the Minister by the end of December 2020.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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 community demand-management actions to reduce avoidable ambulance transport to hospital.

Verbatim wording from the response

“I note your concerns regarding resources available to enable WAST to respond to calls in a timely manner. The Trust is currently implementing the recommendations of an independent capacity and demand review, which will see 136 FTE staff recruited in 2020/21, significantly increasing the number of frontline staff available across the service to respond to incidents. This should support an improvement in responsiveness, although the wider health and care system also has a role to play in enabling improved patient flow through the hospital system and out into the community. This should reduce ambulance patient handover delays and unlock more capacity to respond quickly. A range of actions are also underway to better manage patient demand in the community to help prevent avoidable transport of patients to hospital.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Develop and consult on broader ambulance quality measures for stroke response times, for publication in the New Year.

Verbatim wording from the response

“The Review made nine recommendations and identified a number of areas where further work was required to gain an improved understanding of the challenges and opportunities to improve responses to calls in the ‘Amber’ category. While it did not make any specific conclusions or recommendations relating to ambulance response to stroke, the Emergency Ambulance Services Committee (EASC) is committed to developing the Ambulance Quality Indicators to include a broader range of meaningful measures for strokes and other time dependent conditions, while protecting the integrity of the clinical response model.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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 outstanding recommendations from the all-Wales thrombolysis review with WAST and Health Boards.

Verbatim wording from the response

“We also continue to work with WAST and Health Boards to implement the recommendations of the NHS Wales Delivery Unit All-Wales Thrombolysis Review, published last year. The review identified a number of national cross-cutting themes across Wales that would benefit from an all-Wales approach and made a number of personalised recommendations for WAST and Health Boards to address the variation in the number of people who receive thrombolysis in Wales. Whilst Covid-19 and the retirement of the national clinical lead for stroke has slightly delayed progress, the new clinical lead for stroke in Wales, Dr ████████ is committed to ensuring that all outstanding review recommendations are implemented as soon as possible.”

Source location

2020-0182-Response-from-Welsh-Government-Health-and-Social-Services_Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Develop a Demand Management Plan to coordinate service actions during periods of escalated pressure.

Verbatim wording from the response

“When vehicles are delayed at hospital this effects our ability to respond to patient’s in the community and causes significant pressures upon our services. Accordingly the Trust has developed a Demand Management Plan to manage actions across our services at times of escalated pressure.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Continue working with Health Boards across Wales to address ambulance delays at hospitals.

Verbatim wording from the response

“I can provide you with assurance that the Trust continues to work with all Health Boards across Wales to address the problems associated with our ambulances (be that Emergency, Urgent Care or Rapid Response Vehicles) being delayed at hospital. I personally wrote to the Chief Executive Officers of the Health Boards across Wales in August of this year to share my concerns regarding the pressures on our services when our resources are delayed at hospitals.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 4 · response
Published 19 November 2020

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

Support out-of-hours patient discharge and transfer to release hospital beds and improve emergency department flow.

Verbatim wording from the response

“• We also support the discharge and transfer of patients out of hours in order to release beds in hospitals, which in turn supports the improvement of patient flow in the emergency departments.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 4 · response
Published 19 November 2020

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

Continue recruiting and training Advanced Paramedic Practitioners to treat patients at home where possible.

Verbatim wording from the response

“• We continue to recruit and train Advanced Paramedic Practitioners who have a higher skill level and are trained to treat patients at their own homes, where possible.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 4 · response
Published 19 November 2020

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

Operate the Operational Delivery Unit as a leadership and coordination hub to monitor demand, manage hospital delays and mitigate risks to patient care.

Verbatim wording from the response

“Another action that is being taken forward is to offer support at challenging times include the Operational Delivery Unit (ODU). The ODU is a pilot model designed to provide 24/7 leadership in support of the Welsh Unscheduled Care system, and as a central hub to co-ordinate flow and mitigate potential risks to patient care. To date it delivers 16 hours a day operating between 08:00-midnight, which was reduced in August 2020 to 12 hours a day.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Develop out-of-hospital pathways with Health Boards to safely reduce hospital conveyance.

Verbatim wording from the response

“• We are working in collaboration with the Health Board to develop out of hospital pathways to safely reduce the need to convey patients to hospital.”

Source location

2020-0183-Response-from-Welsh-Ambulance-Services_Redacted.pdf
Page 4 · response
Published 19 November 2020

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