Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Ceriann Richards · 1 Mar 2017 · Andrew Barkley, South Wales Central
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals”
judiciary.uk/prevention-of-future-death-reports/ceriann-richards
What was promised
Stated action 1 · response to Ceriann Richards (1 Mar 2017) · stated timescale: 20 April 2017
“a Health Board we have implemented and reviewed a number of key processes. e An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives. The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing”
judiciary.uk/…/2017-0041-Response-by-University-Health-Board.pdf
What recurred
- 20 Jun 2023 · Leonard Harmsworth · Kate Sutherland · Identical hazard · confidence 0.90 (high)
- 15 Nov 2023 · Lynda Blackmore · Graeme Hughes · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Ceriann Richards · 1 Mar 2017
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals”
Later · Lynda Blackmore · 15 Nov 2023
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
What happened next
No evidence found either way · a stated action in a response
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 · a stated action in a response
“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.