Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Frederick Pring · 21 Jan 2014 · John Gittins, North Wales (East & Central)
“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”
judiciary.uk/prevention-of-future-death-reports/frederick-pring
What was promised
Stated action 1 · response to Frederick Pring (21 Jan 2014) · stated timescale: none stated
“incidents. WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and lower acuity calls”
judiciary.uk/…/2014-0024-Response-by-Welsh-Ambulance-Service.pdf
Stated action 2 · response to Pamela Conway (26 Aug 2016) · stated timescale: none stated
“has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”
judiciary.uk/…/2016-0309-Response-by-University-Health-Board.pdf
Stated action 3 · response to Lilly Baxandall (17 May 2017) · stated timescale: October 2015
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”
judiciary.uk/…/2017-0160-Response-by-University-Health-Board.pdf
1 further stated action is listed on the full chain page.
What recurred
- 26 Aug 2016 · Pamela Conway · John Gittins · Closely related · confidence 0.90 (high)
- 17 May 2017 · Lilly Baxandall · John Gittins · Identical hazard · confidence 0.95 (high)
- 25 May 2017 · Daphne Williams · John Gittins · Identical hazard · confidence 0.90 (high)
- 7 Jul 2017 · Catherine Roberts · Nicola Jones · Closely related · confidence 0.90 (high)
- 10 Sept 2018 · Gladys Williams · John Gittins · Identical hazard · confidence 0.96 (high)
- 11 Feb 2019 · Madeline Staples · John Gittins · Identical hazard · confidence 0.98 (high)
- 7 Nov 2019 · Peter Connelly · John Gittins · Identical hazard · confidence 0.96 (high)
- 20 Feb 2023 · David Strachan · Kate Sutherland · Identical hazard · confidence 0.90 (high)
- 20 Jun 2023 · Leonard Harmsworth · Kate Sutherland · Closely related · confidence 0.90 (high)
- 21 Jun 2023 · Jean Frickel · Kate Sutherland · Identical hazard · confidence 0.90 (high)
- 10 Jul 2023 · Mary Jones · Kate Robertson · Closely related · confidence 0.90 (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 · Madeline Staples · 11 Feb 2019
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
What happened next
No evidence found either way · stated action 1
The Health Board's documents do not include any statement confirming that a review of Welsh MPDS codes and the DCR table will be conducted to broaden response categories.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“A lack of available beds in our hospitals is currently leading to unprecedented ambulance delays across the health board and we are working closely with local authority colleagues to support medically fit patients to be discharged from hospital”
Betsi Cadwaladr health board declares critical incident · bbc.com/news/uk-wales-64025811
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Arrangements for Managing Demand - Betsi Cadwaladr University Health Board Date issued: July 2025 Document reference: 4989A2025 This document has been prepared for the internal use of Betsi Cadwaladr University Health Board as part of work performed/to be performed in accordance with statutory functions.”
Arrangements for Managing Demand – Betsi Cadwaladr ... · audit.wales/…/4989A2025_BCUHB%20Managing%20UEC%20Demand%20Repor…
“Scottish Ambulance Service New Clinical Response Model Evaluation suggests new model accurately identifes patients in greatest need through emergency 999 calls Background The Scottish Ambulance Service (SAS) implemented the New Clinical Response Model (NCRM) for Emergency 999 Calls in November 2016.”
Scottish Ambulance Service New Clinical Response Model · stir.ac.uk/…/Scottish-Ambulance-Service-New-Clinical-Response-M…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”
“New Clinical Response Model (NCRM) for Emergency 999 Calls in November 2016. The NCRM aims to save more lives by more accurately identifying”
Have you had your say yet? We are now at the end of the fifth ... · facebook.com/…/1935905273153130
“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.”
how our service is changing - Welsh Ambulance Services University NHS Trust · ambulance.nhs.wales/services/how-our-service-is-changing
“We use essential cookies to make our site work. We'd like to use additional cookies to understand how you use the site and improve our services.”
Written evidence - AMB0002 · committees.parliament.uk/writtenevidence/165608/html
No evidence found does not mean the action did not happen.