What happened
In April 2021 Janet Winspear, 76, of Tywyn, was recovering from a stroke when a non-emergency ambulance collected her for a 19-mile transfer to an appointment at Dolgellau Hospital.
The crew secured her on the stretcher with three straps, at the legs, hips and chest. They did not use the over-the-shoulder harness that their training required.
On the A470 near Dolgellau the driver drifted into the opposite lane and struck an oncoming van. Winspear was thrown against the inside of the ambulance and died at the scene from severe chest trauma.
The outcome
The driver, 61, of Bangor, denied causing death by careless driving and changed his plea to guilty before trial. He was sentenced at Caernarfon Crown Court on 9 June 2023 to eight months’ imprisonment and disqualified from driving for 16 months.
In mitigation the court was told that non-compliance with the harness requirement was “working practice” among staff at the Welsh Ambulance Service at the time. After the death the trust reissued its guidance on securing patients in the back of ambulances.
What went wrong
The requirement was never in dispute. The harness was part of the crew’s training, three straps went on and the one that would have held her shoulders did not.
The mitigation is the finding that matters. If skipping the harness was working practice across staff, the omission was not one driver deciding against the system. It was the system.
The Association of Ambulance Chief Executives found the same pattern when it surveyed frontline staff in late 2022: many did not know it was the driver’s ultimate responsibility to check that everyone in the vehicle was secure before setting off, and a high proportion had not worn a seat belt at any point on their most recent journey.
What it teaches
A practice that everyone follows and nobody audits is a system hazard, not a training gap. The crew in this case had been trained. What they had learned, from the way the service ran, was that the fourth strap was optional.
Two things follow. The check has to sit with a named person before the vehicle moves, and it has to be a check of the other person’s work, not a self-report. And a crew member has to be able to say “the harness is missing” in the back of a moving ambulance without that being heard as an accusation against a colleague.
Transport is the part of restraint work most services write down least. A plan that covers the hold in the building and stops at the vehicle door misses the part of the journey where nobody can re-position or help.
Questions for the room
- Three straps are on, the shoulder harness is in the locker, and the appointment is soon. What do you say, and to whom?
- You are the driver. Your colleague has secured the patient. What do you physically check before moving off, and what do you do if it is wrong?
Evidence and limits
Confidence: confirmed. Two sources read in full: BBC News reporting the sentencing on 9 June 2023, and the Association of Ambulance Chief Executives’ #SafeInTheBack material, which is the source for the 2022 survey.
One limit worth stating plainly: the death was caused by the collision, not by the straps. This is not restraint injuring someone; it is a case about the standard of securing, which is what a restraint system is in a moving vehicle. The mitigation about working practice was reported to the court rather than found by it, and the entry describes it as the mitigation.
The driver was convicted, so he could lawfully be named. This entry gives his role and not his name.
Our vulnerable and volatile persons training covers acute behavioural disturbance and what to do before hands are used.
Sources
Reviewed 20 October 2026.