Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Diane Greenslade · 21 Dec 2018 · Wendy James, Gwent
“Demand for ambulances was high compounded by excessive delays at hospitals.”
judiciary.uk/prevention-of-future-death-reports/diane-greenslade
What was promised
Stated action 1 · response to Diane Greenslade (21 Dec 2018) · stated timescale: weekly
“The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board's Executive Team each week.”
judiciary.uk/…/2018-0401-Response-by-University-Health-Board.pdf
Stated action 2 · response to Lynda Blackmore (15 Nov 2023) · stated timescale: none stated
“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].”
judiciary.uk/…/2024-0062-Response-from-Nation-Institute-for-Hea…
Stated action 3 · response to Lynda Blackmore (15 Nov 2023) · stated timescale: none stated
“have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”
judiciary.uk/…/2024-0069-Response-from-Aneurin-Bevan-University…
What recurred
- 15 Nov 2023 · Lynda Blackmore · Graeme Hughes
- 22 Jul 2025 · Robyn Chambers · Caroline Saunders · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Diane Greenslade · 21 Dec 2018
“Demand for ambulances was high compounded by excessive delays at hospitals.”
Later · Robyn Chambers · 22 Jul 2025
“the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital.”
What happened next
No evidence found either way · stated action 2
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 3
“Following an assessment against the NHS Wales oversight and escalation framework in November 2025, Aneurin Bevan University Health Board escalation levels are as follows: * Level 4 for finance, strategy and planning * Level 4 for performance and outcomes related to urgent and emergency care”
Aneurin Bevan University Health Board oversight and escalation framework: August 2026 [HTML] | GOV.WALES · gov.wales/…/aneurin-bevan-university-health-board-oversight-and…
“The Auditor General is responsible for auditing most of the public money spent in Wales. Access our data tools and useful data sources The NFI matches data across organisations and systems to help public bodies identify fraud and overpayments. Our programme of shared learning events focusses on topics that are common across public services Our forward work programme for performance audit Insights”
Aneurin Bevan University Health Board – Urgent and Emergency Care: Arrangements for Managing Demand | Audit Wales · audit.wales/…/aneurin-bevan-university-health-board-urgent-and-…
“Aneurin Bevan University Health Board is a multi-award-winning NHS organisation with a passion for caring. The Health Board provides an exceptional workplace where you can feel trusted and valued. Whatever your specialty or stage in your career, we have opportunities for everyone to start, grow and build your career. The health board provides integrated acute, primary and community care serving”
About Us - Aneurin Bevan · abuhb-jobs.co.uk/our-health-board/about-us
No evidence found does not mean the action did not happen.