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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.

 

Health

Decision pending on adult mental health referral pathway

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HYWEL DDA University Health Board will decide next week whether to make changes to the GP referral pathway for routine adult mental health services permanent.

The decision will be taken at a public Board meeting on Thursday (Mar 26).

Board members will consider a proposal to formalise changes already introduced in Ceredigion and, if approved, roll out the revised pathway across Pembrokeshire and Carmarthenshire.

Since March 2025, adults in Ceredigion seeking routine mental health support have been advised by their GP to contact the NHS 111 Wales ‘Press 2’ service, rather than being referred directly to the county’s Community Mental Health Team.

The temporary change was introduced in response to ongoing staffing shortages. Health Board officials say the approach has helped maintain timely access to face-to-face assessments for those who need them, while directing initial contact through a single access point.

The 111 ‘Press 2’ service provides telephone assessments by local wellbeing practitioners, supervised by registered mental health nurses, offering advice, support and onward referrals where required.

At its November 2025 meeting, the Board agreed to extend the temporary pathway until the end of March 2026. A nine-week engagement exercise followed, running from December 8 to February 9, to gather feedback from patients, professionals and stakeholders on the potential long-term impact.

Andrew Carruthers, Chief Operating Officer at Hywel Dda University Health Board, said: “I would like to thank everyone who took the time to share their views and experiences.

“I would also like to thank West Wales Action for Mental Health for supporting engagement with patients, including those with lived experience, alongside GPs, primary care teams, mental health staff and third sector partners.

“Our priority is to ensure mental health services remain accessible, fair and sustainable. The temporary changes in Ceredigion have shown some positive benefits, and the feedback we have received from across the three counties will play an important role in shaping the Board’s decision.”

The Board will review all evidence and feedback before making a final decision on the future of the adult mental health referral pathway.

GPs will continue to refer patients with urgent or complex needs directly to community mental health teams where appropriate, and have access to a dedicated NHS 111 professional line for additional clinical advice.

Further details, including the full Board papers, are available here:
https://biphdd.gig.cymru/amdanom-ni/eich-bwrdd-iechyd/cyfarfodydd-y-bwrdd-2026/agenda-a-phapuraur-bwrdd-26-mawrth-2026/

The meeting will be streamed live from 9:30am on Thursday (Mar 26) via:
www.youtube.com/hywelddahealthboard1

 

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Health

Parents urged to check children’s vaccinations after meningitis cases

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Local pharmacy reports MenB vaccine shortage amid rising concern

PARENTS and carers across west Wales are being urged to check their children’s vaccination status following recent meningitis cases in the UK.

The warning comes as a local pharmacy has confirmed a shortage of the Meningitis B (MenB) vaccine, highlighting growing pressure on supplies.

Mendus Pharmacy said it currently has no availability of the vaccine due to what it described as a nationwide supply issue.

Mendus Pharmacy: No availability of the vaccine

In a statement, the pharmacy said: “We would like to inform our patients that, due to ongoing supply issues, we currently have no availability of the Meningitis B vaccine.

“Unfortunately, this is a nationwide shortage and all stock is currently unavailable.

“We understand this may be particularly concerning given the recent outbreak reported in Kent, and we completely appreciate the importance of timely vaccination.”

The pharmacy confirmed it is operating a waiting list and will contact patients once supplies return.

Health officials say keeping vaccinations up to date remains one of the most effective ways to prevent serious illness and reduce pressure on NHS services.

Dr Ardiana Gjini, Executive Director of Public Health at Hywel Dda University Health Board, urged parents to act.

She said: “Vaccination is one of the most effective ways we can protect children and young people from serious illness.

“Ensuring your child is fully vaccinated not only safeguards their health but also helps prevent the spread of infections within our communities.

“I strongly encourage all parents and carers to check their child’s vaccination status. If you are concerned that your child may have missed routine vaccinations, please speak to your GP.”

Meningococcal disease is a serious and potentially life-threatening infection that can lead to meningitis or septicaemia. While many people recover, some are left with long-term physical, neurological or psychological complications. Around one in ten cases can be fatal.

Although the disease can affect anyone, babies, young children, teenagers and young adults are at greatest risk.

In Wales, vaccines protecting against meningococcal strains A, B, C, W and Y are offered as part of the NHS immunisation programme. Infants receive the MenB vaccine, while teenagers are offered the MenACWY vaccine.

Latest figures from the Health Board show that uptake among 16-year-olds for the MenACWY vaccine stands at 76.4%, meaning a significant number of young people remain unprotected as they approach adulthood.

For younger children, uptake of the MenB vaccine is higher but still below the recommended 95% target. Around 92.8% of infants are vaccinated by their first birthday, rising slightly to 91.8% by their second.

Health officials say these figures reflect strong engagement from families and primary care teams but stress that continued vigilance is needed.

Families are being advised to check their child’s vaccination record with their GP or by contacting the Health Board directly. Parents should also ensure babies receive their scheduled MenB doses and that teenagers receive their MenACWY and 3-in-1 booster vaccines, which are currently being delivered in schools.

Parents are also urged to remain alert to the symptoms of meningitis and septicaemia and to seek urgent medical advice if they have concerns.

Further information on symptoms is available via NHS 111 Wales.

 

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Health

NHS ‘on brink of collapse’ during Covid as inquiry exposes failures

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Wales warned to act fast as damning report reveals staff trauma, delayed care and deadly gaps

THE UK’s healthcare system came perilously close to collapse during the Covid-19 pandemic, a major public inquiry has found, with Wales now facing pressure to act on urgent recommendations.

A landmark report published on Thursday (Mar 19) lays bare the scale of the crisis, concluding that hospitals across the UK – including in Wales – were pushed to “intolerable strain”, with some patients receiving lower levels of care and others left untreated altogether.

The findings come as First Minister Eluned Morgan welcomed the report and confirmed the Welsh Government will respond within six months.

Flawed response: Investigators identified serious failings in how the pandemic was handled

System “ill-prepared” for pandemic

The inquiry found the UK entered the pandemic in a weakened state, with staff shortages, too few hospital beds, and ageing infrastructure already placing pressure on services.

Healthcare systems “coped, but only just,” the report states, warning that collapse was only avoided due to the “almost superhuman efforts” of NHS staff.

Many workers suffered severe mental health impacts, with burnout and post-traumatic stress widespread across the workforce.

Patients died alone

Among the most distressing findings was the impact of strict hospital visiting rules.

Thousands of patients died without family by their side, while relatives were often forced to say goodbye over the phone or by text.

The report highlights how restrictions, though intended to save lives, caused lasting trauma for families across Wales and the UK.

Covid-19: Healthcare systems “coped, but only just,” the report states

Missed treatment and cancer delays

The inquiry also exposes the devastating knock-on effect on non-Covid care.

Planned operations were cancelled, screening programmes paused, and patients avoided hospitals out of fear – leading to delayed diagnoses and, in some cases, avoidable deaths.

Cancer treatment performance worsened, with late diagnoses contributing to increased mortality.

“Fundamental flaws” in response

Investigators identified serious failings in how the pandemic was handled, including:

  • Early guidance that underestimated airborne transmission
  • Shortages of PPE, leaving staff exposed
  • Poor communication with vulnerable patients
  • Inadequate planning for emergency and critical care capacity

These issues, the report says, put both patients and staff at greater risk.

Ambulances overwhelmed: The report warns future pandemics could see similar failures unless urgent reforms are made

NHS 111 and ambulances overwhelmed

Emergency systems also struggled to cope.

Demand for NHS 111 surged beyond capacity, while ambulance delays increased – even for life-threatening calls.

The report warns future pandemics could see similar failures unless urgent reforms are made.

Long Covid and hidden impact

The long-term effects of Covid are still being felt, with inconsistent care for Long Covid patients and ongoing uncertainty around treatment.

Meanwhile, millions of people who needed routine care remain affected by the backlog created during the pandemic.

Eluned Morgan: Acknowledged the significant impact on patients, staff and families

Welsh Government response

First Minister Eluned Morgan said the Welsh Government would respond “openly and constructively” to the findings.

She acknowledged the significant impact on patients, staff and families and confirmed Wales will address the inquiry’s recommendations within the required six-month timeframe.

Urgent warnings for the future

The inquiry makes ten key recommendations, including:

  • Expanding hospital and emergency capacity
  • Improving infection control guidance
  • Strengthening support for healthcare workers
  • Better data systems to identify vulnerable patients

It warns that without action, the NHS may not withstand the next pandemic.

“We may not be so lucky next time”

In one of the report’s starkest conclusions, Baroness Hallett warned that healthcare systems came dangerously close to failure.

If the crisis had lasted longer – or hit harder – the NHS could have collapsed entirely.

The message is clear: Wales and the UK must prepare now, or risk repeating the same mistakes.

 

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