PFD report

Glenys Roberts · Prevention of Future Deaths report

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Issued 24 Oct 2022•North West Wales

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
Recipients: 2
Responses found: 2
Stated actions: 15

Recipients and published responses

Betsi Cadwaladr University LHBResponse found Welsh Ambulance Services NHS TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 26 August 2021, an investigation was commenced into the death of Glenys Roberts.

The investigation concluded at the end of an Article 2 compliant Inquest on 18 October 2022. A narrative conclusion was given:-

At around 5pm on 23 August 2021 Glenys Roberts was found by a passer-by on the floor by her front door. Glenys Roberts was complaining of pain and loss of sensation in her legs. She was conveyed to Ysbyty Gwynedd and arrived at 19.46. Assessment in the Emergency Department of Ysbyty Gwynedd led to a diagnosis of saddle embolus of the aortic bifurcation. With vascular across the Health Board centralized at Ysbyty Glan Clwyd, some 30 miles away, the Consultant at Ysbyty Gwynedd discussed Glenys Robert’s case with the vascular consultant on call based at Ysbyty Glan Clwyd at 21.19 hours who advised 5000 unit bolus dose of intravenous heparin and CT angiogram an emergency ambulance transfer to Ysbyty Glan Clwyd. The CT angiogram revealed a complete occlusion of the distal aorta. Arrangements were made for Glenys Roberts to be admitted directly onto a ward at Ysbyty Glan Clwyd rather than being admitted via the Emergency Department to prevent delays whilst being admitted. There was, however, a failure to convey Glenys Roberts by ambulance from Ysbyty Gwynedd to Ysbyty Glan Clwyd in a timely manner or at all for vascular surgery. Glenys Roberts continued to deteriorate and became too frail to be conveyed to Ysbyty Glan Clwyd when an ambulance became available at 05:15. Glenys Roberts was certified deceased in Ysbyty Gwynedd at 07.39 on 24 August 2021. There was a missed opportunity for Glenys Roberts to undergo vascular surgery by not being conveyed to Ysbyty Glan Clwyd thereby failing to optimize an opportunity for life saving surgery but it cannot be said that this would have altered the outcome for her.

Concerns and recipient responses

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

Concerns raised3

Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability
Part of recurring concern: Delays in ambulance-to-hospital patient handover Part of recurring concern: Inadequate system planning for ambulance-delay pressures
Delays in reviewing and acting on intra-hospital transfers
Failure of the vascular emergency transfer pathway to provide direct hospital admission
Part of recurring concern: Failure to provide timely hospital admission Part of recurring concern: Unreliable emergency access to hospital care

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 11

Action
Continue reviewing intra-hospital transfers, modelling service demand and developing an options appraisal to support required additional resources.
Stated by Betsi Cadwaladr University LHBStated in progress
Action
Implement the agreed bolus-dose anticoagulant protocol to enable non-paramedic crews to convey patients between hospitals.
Stated by Betsi Cadwaladr University LHBStated completed
Action
Map the emergency ischaemic limb patient journey across North Wales hospitals, identify delays and bottlenecks, and take steps to reduce them.
Stated by Betsi Cadwaladr University LHBStated in progress

Action
Commence the vascular emergency bypass pathway for direct admission of suitable stable patients to the vascular ward and monitor its implementation until embedded.
Stated by Betsi Cadwaladr University LHBStated in progress
Action
Share the local Ysbyty Gwynedd ambulance handover plan and related emergency department and hospital protocols across Health Board sites for local adoption.
Stated by Betsi Cadwaladr University LHBStated completed
Action
Implement the protocol for the Ambulance Critical Care Team to transfer patients when paramedic crews cannot transfer them between hospital sites promptly.
Stated by Betsi Cadwaladr University LHBStated completed
Action
Work fortnightly with BCU Health Board and NCCU through an action plan to improve ambulance resource availability for intra-hospital transfers.
Stated by Welsh Ambulance Services NHS TrustStated in progress
Action
Operate the implemented vascular bypass protocol across the South East Wales Vascular network for conditions including abdominal aortic aneurysm and ischaemic limb.
Stated by Welsh Ambulance Services NHS TrustStated completed
Action
Develop and commission a longer-term intra-hospital transfer model, including potential dedicated transfer resources, following demand validation and cross-organisation collaboration.
Stated by Welsh Ambulance Services NHS TrustStated in progress
Action
Finalise and implement the vascular emergency bypass pathway with BCU Health Board, including direct hospital admission arrangements and operational contact and destination details.
Stated by Welsh Ambulance Services NHS TrustStated in progress
Action
Maintain the Handover Improvement Plan with BCU Health Board and NCCU, using integrated commissioning action plans and fortnightly meetings to improve system flow and ambulance availability.
Stated by Welsh Ambulance Services NHS TrustStated in progress

Respondent positions 2

Position
The vascular pathway cannot be released for immediate use until the Health Board provides a contact number and destination.
Stated by Welsh Ambulance Services NHS TrustUnable to act

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 4

1
Review ambulance performance fortnightly with the NHS Wales Delivery Unit against delay-reduction targets.
Stated by Betsi Cadwaladr University LHBStated in progress
2
Complete the integrated commissioning action plan to support rapid improvement in ambulance performance and urgent and emergency care.
Stated by Betsi Cadwaladr University LHBStated completed
3
Table the Reducing Patient Harm Action Plan at Trust Board meetings to support reduced lost ambulance hours and improved response times.
Stated by Welsh Ambulance Services NHS TrustStated completed
4
Work with BCU Health Board to develop non-conveyance pathways that support improved system flow.
Stated by Welsh Ambulance Services NHS TrustStated in progress

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability

Delays in reviewing and acting on intra-hospital transfers

Failure of the vascular emergency transfer pathway to provide direct hospital admission

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.11

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

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.4

Actions described in response 11

Respondent positions 2

Recipient-stated actions 4