PFD report

Clive Harold Turner · Prevention of Future Deaths report

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Issued 12 Sep 2014•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.

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Concerns
6

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
17

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 raised6

  1. Delays in the provision of ambulance assistance
    Part of recurring concern: Delays in ambulance attendance
  2. Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
  3. Failure to ensure emergency clinicians know what pain relief has already been provided
    Part of recurring concern: Failure to provide timely and adequate pain relief
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.12

  1. Action

    Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 September 2014.
  2. Action

    Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
  3. Action

    Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 September 2014.

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 the provision of ambulance assistance

Wider context from the report

“1. That there were significant delays in the provision of assistance to Mr Turner by the Welsh Ambulance Service ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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 Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability

Wider context from the report

“2. That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover.

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 to ensure emergency clinicians know what pain relief has already been provided

Wider context from the report

“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate pain relief.

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 senior clinicians for overnight second opinions

Wider context from the report

“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”

Is this part of a recurring concern?

Yes — Failure to provide effective senior clinical oversight of patient care; Unreliable clinical second-opinion processes.

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 to rectify previously identified patient handover delays

Wider context from the report

“3. It is of considerable concern to me that item 2 above is a direct repeat of a concern which I raised in a previous Regulation 28 report following the death of Mr Frederick Pring in March 2013, twelve months before that of Mr Turner, the joint response of WAST and BCUHB being received exactly one week before Mr Turner's death. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning.

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 emergency clinicians’ awareness of overnight patient-discharge policies

Wider context from the report

“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”

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

Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.

Verbatim wording from the response

“To prevent this break down in communication in the future, the Trust has developed a clear process for escalating calls where a delayed face to face assessment (i.e. ambulance response) is offset by gaining additional clinical assistance from NHSDW, who can undertake a telephone assessment in the absence of an ambulance response. This will be in place from 1 December 2014.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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 revised ambulance handover safety audit across the Health Board and report its results monthly.

Verbatim wording from the response

“The audit of ambulance handover to provide assurance in relation to patient safety during this period of care has been revised by the BCUHB Associate Medical Director for Unscheduled Care. The new process has been piloted at one of the Emergency Departments in North Wales and following some amendment will be implemented across BCUHB and reported monthly. This has already commenced in Ysbyty Glan Clwyd.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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

Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.

Verbatim wording from the response

“BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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

Investigate serious incidents involving both organisations jointly and share the resulting learning.

Verbatim wording from the response

“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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 holding areas in each Emergency Department when required to enable safe, timely patient offloading.

Verbatim wording from the response

“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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

Consult on and ratify a North Wales escalation protocol before implementing it across the area.

Verbatim wording from the response

“BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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

Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.

Verbatim wording from the response

“BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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 cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.

Verbatim wording from the response

“There is engagement at all levels between the Trust and BCUHB, with conference calls arranged to agree joint action plans to address ongoing delays. Duty Control Managers from the Trust will initially contact the Hospital Clinical Site Managers if ambulances are delayed. The escalation process will continue with the Trusts Locality Managers contacting the Senior Site Operational Managers in BCUHB and then the Trusts Head of Service engaging with the Chief Operating Officer within BCUHB out of hours as there is an ‘On Call’ system Bronze to Bronze, Silver to Silver and Gold to Gold engagement between both organisations to ensure that a seamless escalation process exists.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

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 a Wales-wide Clinical Desk staffed by paramedics and nurses to provide secondary triage and clinical support for delayed calls.

Verbatim wording from the response

“Clinical Desk The Trust is introducing a Clinical Desk into the Clinical Contact Centre in Vantage Point House, Cwmbran, which will be in operation for the whole of Wales. This will comprise of Paramedics and Nurses providing further early triage of calls using the Manchester Triage System to ensure the correct and most appropriate response is sent to meet the clinical needs of the patient. This will be implemented by the Trust in December 2014 and provides:”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 4 · response
Published 12 September 2014

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

Review and align Welsh Medical Priority Dispatch System codes with other UK ambulance services using the system.

Verbatim wording from the response

“Improvement to Call Prioritisation Like many other UK ambulance services, the Trust uses the international accredited Medical Priority Dispatch System (MPDS). This is a unified system for consistent call handling of”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

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 senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.

Verbatim wording from the response

“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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 the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.

Verbatim wording from the response

“BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014

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.5

  1. 1

    Monitor implementation of the safety initiatives through assurance and performance management arrangements, including Board-level progress reviews.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
  2. 2

    Test Paramedic Pathfinder and develop alternative care pathways in Conwy and Denbighshire.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
  3. 3

    Promote alternative transport for clinically suitable low-acuity patients to preserve ambulance availability for life-threatening calls.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.
  4. 4

    Implement Paramedic Pathfinder in the remaining North Wales localities.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 September 2014.
  5. 5

    Update the Rest Break Policy to allow staff to take breaks at the nearest suitable location and use hospital facilities where appropriate.

    Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.

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

Monitor implementation of the safety initiatives through assurance and performance management arrangements, including Board-level progress reviews.

Verbatim wording from the response

“In conclusion, we hope that this joint response from BCUHB provides you with the assurances you require in response to the content of your Regulation 28 letter dated 12 September 2014. Both organisations are committed to learn lessons from this difficult case and ensure that patient outcomes are improved with more effective clinical care without delays. The necessary improvements are being implemented as quickly as possible, and both organisations will continue to monitor these actions as a part of their assurance/performance management arrangements. This will include Board level review of progress reports.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 4 · response
Published 12 September 2014

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 Paramedic Pathfinder and develop alternative care pathways in Conwy and Denbighshire.

Verbatim wording from the response

“Paramedic Pathfinder Paramedic Pathfinder is a field guide (decision tool) to support on-scene decision making in relation to the most appropriate point of care for the patient. This is being tested in Conwy and Denbighshire since September 2014. The testing involves developing and introducing alternative care pathways to provide patients with the treatment and care they need, and thereby, potentially reducing the number of patients needing to be transported to Emergency Departments. Paramedic Pathfinder will be implemented in the remaining localities of North Wales during the next three months.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

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

Promote alternative transport for clinically suitable low-acuity patients to preserve ambulance availability for life-threatening calls.

Verbatim wording from the response

“Alternative Transport An initiative to promote alternative transport to convey low acuity patients to hospital has been implemented. It has been identified that there are a number of low acuity patients that are clinically safe and suitable to travel to hospital by alternative means, either with family, friends or in a taxi. The aim is to ensure that the Trusts resources are more readily available to attend immediately life-threatening calls. This practice was implemented in North Wales on 1 September 2014.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

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 Paramedic Pathfinder in the remaining North Wales localities.

Verbatim wording from the response

“Paramedic Pathfinder Paramedic Pathfinder is a field guide (decision tool) to support on-scene decision making in relation to the most appropriate point of care for the patient. This is being tested in Conwy and Denbighshire since September 2014. The testing involves developing and introducing alternative care pathways to provide patients with the treatment and care they need, and thereby, potentially reducing the number of patients needing to be transported to Emergency Departments. Paramedic Pathfinder will be implemented in the remaining localities of North Wales during the next three months.”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

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

Update the Rest Break Policy to allow staff to take breaks at the nearest suitable location and use hospital facilities where appropriate.

Verbatim wording from the response

“Rest Breaks for Trust Staff The Trust further updated its Rest Break Policy in August 2014 to facilitate staff taking their breaks at the nearest suitable location. These locations include base stations, other ambulance stations, stand-by points or NHS locations which has fully functioning canteen/catering facilities (e.g. at hospitals).”

Source location

2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014

Open published response
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Data last updated 7 September 2026