Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Pamela Conway · 26 Aug 2016 · John Gittins, North Wales (East and Central)
“That notwithstanding changes which have been made by both BCuHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
judiciary.uk/prevention-of-future-death-reports/pamela-conway
What was promised
Stated action 1 · response to Pamela Conway (26 Aug 2016) · stated timescale: 2016-05-05
“we have made progress against key actions which are all identified in the attached action plan”
judiciary.uk/…/2016-0309-Response-by-Welsh-Ambulance-Service.pdf
Stated action 2 · response to Richard Barrett (30 Jul 2018) · stated timescale: end of this month
“WAST has reported that at times of increased demand, capacity to undertake welfare calls is reduced and it is currently considering options to increase capacity on its clinical support desk which provides support and advice over the telephone, as well as opportunities for third sector organisations and other agencies (e.g. Police, Fire and Rescue Services) to support the delivery of welfare checks, particularly for patients who have experienced a delayed response.”
Stated action 3 · response to Glenys Roberts (24 Oct 2022) · stated timescale: Quarter 4 of this financial year
“The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers.”
judiciary.uk/…/2022-0333-Response-from-Welsh-Ambulance-Services…
4 further stated actions are listed on the full chain page.
What recurred
- 17 May 2017 · Lilly Baxandall · John Gittins
- 6 Jun 2018 · Ester Wood · David Pojur · Identical hazard · confidence 0.90 (high)
- 26 Jun 2018 · Margaret Evans · John Gittins · Identical hazard · confidence 0.93 (high)
- 30 Jul 2018 · Richard Barrett · Rachel Knight
- 11 Feb 2019 · Madeline Staples · John Gittins · Identical hazard · confidence 0.90 (high)
- 24 Oct 2022 · Glenys Roberts · Kate Sutherland · Closely related · confidence 0.90 (high)
- 21 Jun 2023 · Jean Frickel · Kate Sutherland
- 15 Nov 2023 · Lynda Blackmore · Graeme Hughes · Identical hazard · confidence 0.92 (high)
- 22 Oct 2024 · Peter Parker · Aled Gruffydd · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Lilly Baxandall · 17 May 2017
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later · Margaret Evans · 26 Jun 2018
“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”
What happened next
No evidence found either way · stated action 1
“Part 1: Performance Report which details how the Trust performed in the year and how we adapted and responded to the system pressures currently impacting our patients and our people.”
Annual Report and Accounts 2023/24 · senedd.wales/media/kradakae/gen-ld16576-e.pdf
“Governance: The Trust has strengthened governance arrangements, although performance in key areas is not improving as”
Welsh Ambulance Services NHS Trust · audit.wales/…/welsh_ambulance_nhs_trust_structured_assessment_2…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“The child welfare system can have devastating short- and long-term impacts on children and families. Families experiencing poverty should be met with sup-port rather than pushed into this potentially harmful system. Yet, when families with low incomes and Black families come into contact with health care pro-viders, they are disproportionately funneled into the child welfare system due to existing”
Medical-Legal Partnerships as Tools to Reduce Child Welfare ... · law.georgetown.edu/…/medical-legal-partnerships.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Integrated Medium Term Plan 2026-2029 Summary”
Publications - Welsh Ambulance Services University NHS Trust · ambulance.nhs.wales/about-us/publications
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines.”
“The Welsh Ambulance Service has changed the way it deals with 999 calls. New Orange, Yellow and Green categories replaced the former Amber and Green categories in December 2025. Together with the Purple and Red categories introduced in July 2025 for life-threatening calls, there are now five categories of calls, all designed to ensure patients get the right care for their needs.”
how our service is changing - Welsh Ambulance Services University NHS Trust · ambulance.nhs.wales/services/how-our-service-is-changing
“The primary remit for NHS ambulance services will always be to provide emergency response to those who have life-threatening health needs, and to major incidents as Category 1 civil contingencies responders.”
five-year strategy - 2026-2030 · aace.org.uk/…/AACE-Five-Year-Strategy-2026-2030-V2.1-Feb26.pdf
“Providers covering the Aneurin Bevan University Health Board area: Ambulance Providers: - 121 Medical Services - contact 07855 049647 or 07538 813731 - All Wales Ambulance Service Ltd - contact 01639 830253 - Cartello Ambulance Service - contact 08454 599968”
Welsh Ambulance Service Non-Emergency Patient Transport Service (NEPTS) · 111.wales.nhs.uk/…/ViewLocalService.aspx?id=8173&s=Non-Emergenc…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU.”
“Healthcare Inspectorate Wales (HIW) has assessed the progress made by Welsh Ambulance Services University NHS Trust (WAST) since reviews published in 2020 and 2021. Those reviews considered the management of patients by emergency call centres and the safety, dignity and experience of patients affected by delayed ambulance handovers.”
HIW finds improvements in Welsh Ambulance Services, but delayed patient handovers remain a challenge | Healthcare Inspectorate Wales · hiw.org.uk/…/hiw-finds-improvements-welsh-ambulance-services-de…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
The organisation's statement about producing guidelines for fever in under 5s, sepsis, and sore throat is not supported by any source evidence.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
“It will provide the reader with detail on the Trust's performance and how we responded to changing demands and challenges in 2023/24.”
Annual Report and Accounts 2023/24 · senedd.wales/media/kradakae/gen-ld16576-e.pdf
“Summary ............................................................................................................................ 5 Background ........................................................................................................................ 5 999 Emergency Medical Services ...................................................................................... 7 Remote”
Welsh Ambulance Services University NHS Trust Public ... · gov.wales/…/wast-public-accountability-meeting-evidence-pack.pdf
“Document Title: Planning to Safely Reduce Avoidable Conveyance Publishing approval number: Version number: 01 First published: 22 July 2019 Updated: Prepared by: [name redacted]: OFFICIAL This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact the Central Ambulance Team”
Planning to Safely Reduce Avoidable Conveyance · england.nhs.uk/…/planning-to-safetly-reduce-avoidable-conveyanc…
No evidence found does not mean the action did not happen.