Glenys Roberts
24 Oct 2022 · Coroner Kate Sutherland · North West Wales
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. no ambulance resources to transfer patients
“There were no available ambulance resources to convey [the deceased] from Ysbyty Gwynedd to Ysbyty Glan Clwyd”
2. slow intra hospital transfers
“Review of and action relating to intra hospital transfers has been too slow”
3. inefficient vascular emergency transfer pathway
“Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow”
4. absence of ambulance handover plan
“Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
This report
“There were no available ambulance resources to convey [the deceased] from Ysbyty Gwynedd to Ysbyty Glan Clwyd.”
Closely relatedConfidence 0.90 · high
This report
“Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow”
Later report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Responses
2022-0333-Response-from-Betsi-Cadwaladr-University-Health-Board-.pdf ↗· Betsi Cadwaladr University Local Health Board
Stated action · 01 December 2022
“Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not operational and has been too slow”
2022-0333-Response-from-Welsh-Ambulance-Services-NHS-Trust.pdf ↗· Welsh Ambulance Service NHS Trust
Stated action · 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.”
Stated action · 22 November 2022
“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.”
Stated action · December 2022
“The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU.”