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Ambulance error admitted in 999 call before Pembrokeshire mother’s death

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AN ERROR in handling a 999 emergency call made on Christmas Day has been admitted by the Welsh Ambulance Service Trust (WAST) at a recent inquest hearing, following the death of 40-year-old Pembrokeshire mother, Charlotte Burston.

At the pre-inquest hearing held on Friday (Sept 13), WAST acknowledged a critical mistake in responding to urgent calls for medical assistance. Representing WAST, Trish Gaskell stated, “An advanced paramedic practitioner would normally be allocated and should have been allocated to Ms Burston before she was conveyed to hospital. The trust has accepted that error.”

Deputy Coroner Mark Layton confirmed that all reports from WAST, including transcripts of the 999 calls, had been received. He announced plans to commission an independent expert to review the evidence and determine whether a different response from the ambulance service might have altered the outcome. “The expert will examine the evidence and ascertain whether a difference could have been achieved or not had the ambulance service’s response been different,” Mr Layton said.

Charlotte’s family has been left grieving after her death on New Year’s Eve, despite repeated attempts by her 15-year-old daughter, Ella, to call for medical assistance. On Christmas morning, Charlotte began experiencing severe tingling sensations in one of her arms—a potential warning sign of a cardiac event.

“I called 111 at 8:19 am; the call lasted 53 seconds, so I hung up because it was taking too long,” Ella recounted. “I then called 999 at 8:29 am, and the call lasted 41 minutes. The woman I spoke to refused to tell me how long an ambulance would take but just said that one would be arranged.”

Despite these urgent pleas, no ambulance arrived. As Charlotte’s condition worsened, Ella contacted her grandfather, Brian Laye, who lives in Clunderwen. He immediately drove to Llanteg, arriving to find his daughter drifting in and out of consciousness.

“Charlotte was lying on the sofa, struggling to breathe,” Mr Laye recalled. “We were told an ambulance wouldn’t be available for at least an hour and a half. With no time to lose, I decided to take her to Withybush Hospital myself.”

En route to the hospital, Charlotte suffered a major heart attack near Robeston Wathen. Upon arrival at Withybush General Hospital, she was placed on life support and later transferred to Morriston Hospital. Sadly, she never regained consciousness and was pronounced dead on New Year’s Eve.

A post-mortem examination concluded that the cause of death was hypoxic brain injury—a lack of oxygen to the brain resulting from the cardiac arrest.

“If an ambulance had got to Charlotte within 15 minutes of Ella’s first call, she’d still be with us today,” said Vincent Laye, the father of Charlotte’s daughters. “The pain and the grief that this has left us with is beyond explanation. Our girls have lost a mother who they relied on and who was their best friend.”

Mr Laye expressed deep frustration over what he perceives as systemic failures within the National Health Service (NHS) and WAST. “The bottom line is that the NHS has failed in providing the care that everyone pays for and that every one of us deserves,” he stated.

He added that while schools and local charities like the Sandy Bear Children’s Bereavement Charity are offering support, there has been “absolutely no support” from other authorities. “I truly believe that this awful death could have been prevented,” he said. “Somebody needs to be held accountable for what’s happened, to prevent this from happening to somebody else.”

The depth of the family’s loss was evident as over 150 people attended Charlotte’s funeral. “Our girls have lost a mother who was with them and who cared for them 24/7,” Mr Laye said. “The community around Llanteg has lost a woman who was greatly loved.”

This heartbreaking incident is not isolated. In a similar case, a man in Pembroke Dock died after reportedly waiting nine hours for an ambulance that failed to arrive in time. Despite multiple calls for help, medical assistance did not reach him promptly, leading to his untimely death.

Family members of the deceased have expressed profound grief and frustration, citing systemic issues within emergency services. “The pain we are experiencing is immeasurable,” a relative said. “No one should have to endure such a wait in an emergency.”

These successive tragedies have intensified public outcry over ambulance response times and resource allocation within WAST. Community leaders and residents are demanding urgent action to address these shortcomings to prevent further loss of life.

Liam Williams, Executive Director of Quality and Nursing at WAST, extended condolences to the Burston family. “We were deeply sorry to hear about Ms Burston’s passing and would like to extend our thoughts and condolences to her family on their sad loss,” he said. “A thorough investigation has begun, and we will be contacting Ms Burston’s family to invite them to participate in this process.”

Sonia Thompson, WAST’s Assistant Director of Operations, acknowledged the extreme pressures on the ambulance service due to wider NHS system issues. “Our ambulance service is under extreme and well-documented pressure as a result of wider system pressures across the NHS,” she noted. “We’re thinking very differently about the way we deliver services in future and are already testing some new ways of working across Wales to understand how we can relieve some of the pressure.”

The Welsh Government has stated that despite budget pressures, it is investing in same-day emergency care, extra community beds, and social care services to improve patient flow through hospitals. “We recognise the challenges faced by emergency services and are committed to supporting initiatives that enhance response times and patient care,” a spokesperson said.

Mr Laye emphasised that the issue extends beyond his family’s tragedy. “This is about every other person out there who deserves to be looked after when they are most in need,” he said. “The NHS and the local authority have failed us in a way that’s going to change our lives forever, and I’m refusing to allow this to be brushed aside.”

Local officials and healthcare advocates are calling for a thorough investigation into both cases, urging the Welsh Government to implement necessary reforms. The recurring nature of these tragedies underscores the urgent need for improved resource allocation, staffing, and operational protocols within WAST.

As the inquest proceeds, the Burston family and the wider community await answers. The repeated failures in emergency response have prompted calls for systemic reforms within WAST and the NHS in Wales. Without significant changes, the safety and well-being of the public remain at risk.

Ms Burston is survived by her two daughters, whose prompt actions highlight the critical importance of effective emergency services. The family’s plight serves as a stark reminder of the real-life consequences of systemic shortcomings in healthcare provision. Their hope is that by sharing their story, they can prevent similar tragedies from occurring in the future.

The next pre-inquest hearing is scheduled for January 17, where it is hoped that the details for the full inquest will be finalised.

Charity

Motorcycle fundraisers transform children’s play area at Glangwili Hospital

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Long-running 3 Amigos and Dollies group marks 25 years of support

THANKS to outstanding fundraising by the Pembrokeshire-based 3 Amigos and Dollies Motorcycle Group, Hywel Dda Health Charities has funded a major improvement of the outdoor play area at Cilgerran children’s ward in Glangwili Hospital — a project costing more than £15,000.

The 3 Amigos and Dollies have supported Hywel Dda University Health Board’s children’s services for twenty-five years, with their Easter and Christmas toy runs becoming landmark dates in the local calendar, drawing hundreds of bikers and supporters from across west Wales.

The latest funding has delivered a full transformation of the ward’s outdoor space, including a re-sprayed graffiti wall, new toys and play equipment, a summer house, improved storage, and a moveable ramp to make the area more accessible for young patients. Members of the group even volunteered to help paint and refresh the space themselves.

Paula Goode, Service Director for Planned and Specialist Care, said: **“We are so grateful to the 3 Amigos and Dollies Motorcycle Group for their amazing support. Not only have they raised an incredible amount for the ward, but they have given their time to help make the outdoor space as special as possible.

“Outdoor play greatly reduces stress and anxiety for children, and it provides a vital opportunity to meet other young people going through similar experiences. It benefits both their physical and mental wellbeing, so we couldn’t be happier with the transformation.”

Tobi Evans, a volunteer with the fundraising group, said: “Because of the generosity of everyone who donates, we are able to give thousands each year. We are always humbled by how much people give, and it’s thanks to them that we’ve reached our 25th year.”

Katie Hancock, Fundraising Officer for Hywel Dda Health Charities, added: “We can’t thank the 3 Amigos and Dollies enough for their support for Cilgerran ward. You have put a smile on so many faces. Diolch yn fawr!”

Hywel Dda Health Charities funds items, equipment and activities that go beyond core NHS funding, making a meaningful difference to children and families across mid and west Wales.

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Health

Patients treated in store cupboards as corridor care ‘normalised’

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PATIENTS are being treated in store cupboards, break rooms and toilets as so-called corridor care becomes the norm in Welsh hospitals, the Senedd has heard.

Senedd Members warned treating patients in inappropriate areas has become a “daily reality” rather than an exception as they debated calls for the practice to be eradicated.

The debate was prompted by a petition – submitted by the Royal College of Nursing (RCN) and British Medical Association (BMA) – which gathered more than 10,000 signatures.

Petitioners demanded that keeping patients on trolleys or chairs for a long time be formally classified as a “never event” – a serious, preventable safety incident that should not happen.

But the Welsh Government rejected the calls, arguing the strict definition of a “never event” applies only to preventable medical mistakes – not systemic capacity pressures.

The petition urged ministers to start reporting on corridor care, pause reductions in hospital beds, invest in community care, and prioritise prevention and early intervention.

Sharing her own experience, Reform UK’s Laura Anne Jones argued corridor care is one of the clearest signs of a health service that has been allowed to fall into crisis.

Reform UK's South Wales East MS Laura Anne Jones
Reform UK’s South Wales East MS Laura Anne Jones

“I was placed on a broken bed in a corridor for two nights before a room became available,” she said. “I was in too much pain to care at the time but those caring for me said how completely inappropriate it was and kept apologising for it.”

Ms Jones added: “I could hear private conversations between consultants, doctors and nurses about other patients. And I was right against a curtainless window… there was no dignity, no privacy, and that’s just not OK.”

The Conservatives’ Joel James told the Senedd thousands of patients are now being treated on trolleys in corridors, in ambulances, store cupboards and other places not meant for care. “This is putting life at risk,” he said. “They are being treated without proper facilities.”

Mr James warned: “NHS Wales doesn’t even collect data on who is being treated in a corridor. That frankly should surprise no-one, as Welsh Labour’s philosophy has always been, if you don’t measure it, then there is no evidence to pin you down on it.”

Conservative MS Janet Finch-Saunders
Conservative MS Janet Finch-Saunders

His Tory colleague Janet Finch-Saunders said: “I even know of situations where a paramedic will leave a patient in an ambulance with a new paramedic coming on. When that paramedic comes back on the next shift, the same patient is still in that ambulance

“How can that be morally right? It’s inhumane, it’s cruel and it’s certainly unacceptable.”

Mabon ap Gwynfor, Plaid Cymru’s shadow health secretary, warned the “demeaning and dangerous” practice has become an “almost inescapable” part of hospital care.

“What should be the exception has now been normalised,” he said.

Plaid Cymru MS Mabon ap Gwynfor
Plaid Cymru MS Mabon ap Gwynfor

Rhys ab Owen, who sits as an independent, highlighted reports of patients being cared for in “car parks, break rooms and even toilets”.

Labour’s Carolyn Thomas, who chairs the Senedd’s petitions committee, warned that RCN and BMA members view corridor care as a “systemic national crisis”.

Responding to the debate on Wednesday December 10, Jeremy Miles acknowledged that corridor care “compromises patient dignity and staff wellbeing”.

Health secretary Jeremy Miles
Health secretary Jeremy Miles

But Wales’ health secretary insisted that designating corridor care as a “never event” was not the solution. “The delivery of care in undesignated or non-clinical environments doesn’t meet the criteria due to the complexity of underlying causes,” he said.

Mr Miles told the Senedd: “We do not endorse routine care in non-clinical environments. Our goal is to eliminate this practice through system-wide reform.

“Eradicating care in undesignated or non-clinical environments will not be a simple quick fix. It requires co-ordinated action across health and social care.”

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Health

Hywel Dda brings back face masks in all clinical areas as winter viruses rise

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Health board urges public to help protect vulnerable patients

From today (Thursday, December 11, 2025), Hywel Dda University Health Board has reintroduced mandatory face masks for all visitors and staff in clinical and patient-facing areas as cases of flu and other respiratory viruses continue to rise across west Wales.

The health board says the number of patients needing care for respiratory illnesses has been “increasing at a steady rate”, prompting the return of precautionary measures. All staff — regardless of role — must now wear a surgical mask when in clinical environments or interacting with patients, unless otherwise advised through PPE guidance. Visitors must also wear masks when entering clinical areas, including when attending appointments at hospitals and community sites.

Sharon Daniel, Director of Nursing, Quality and Patient Experience, said the precaution was necessary to prevent further spread within local hospitals.

“We are seeing a growing number of people with flu and other respiratory viruses needing our care and need to take this proactive step to limit the spread within our services and sites,” she said. “This change is effective immediately and our Infection Prevention colleagues will be reviewing the situation on a regular basis.”

Ms Daniel reminded visitors not to attend hospitals if unwell.
“You should only come to our sites if you are feeling well, and to wait 48 hours after you are free of flu and cold-like symptoms, or sickness and diarrhoea. This helps protect our most vulnerable patients and keeps staff well so they can look after those in greatest need.”

While visiting remains open, Hywel Dda warned this could change at short notice if virus levels continue to increase.

Masks will be available at all hospital and community site entry points.

Health board urges public support

Ms Daniel added: “There are several ways people can support our NHS during this time. Please follow the mask-wearing guidance and ensure that you wash your hands regularly with soap and warm water.

“A simple way to keep ourselves and our loved ones safe this winter is to have a flu vaccination. Information on where you can get your vaccine — including RSV and COVID-19 boosters if eligible — is available on our website.”

More information about vaccination clinics can be found at hduhb.nhs.wales/fluvaccine.
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