Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed ambulance response to critically unwell patient
The earlier warning
Ronald Hamer · 20 Apr 2016 · Graeme Hughes, South Wales Central
“As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes.”
judiciary.uk/prevention-of-future-death-reports/ronald-hamer
What was promised
Stated action 1 · response to Ronald Hamer (20 Apr 2016) · stated timescale: 9 June 2016
“Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”
judiciary.uk/…/2016-0149-Response-by-Welsh-Ambulance-Services-N…
Stated action 2 · response to Andrew Collins (2 Oct 2018) · stated timescale: none stated
“The Trust acknowledges your concerns regarding our lack of resourcing, which meant that there was a significant delay in attending to a critically unwell patient.”
judiciary.uk/…/2018-0336-Response-by-Welsh-Ambulance-Services-N…
What recurred
- 2 Oct 2018 · Andrew Collins · Andrew Barkley · Closely related · confidence 0.90 (high)
- 6 Jul 2023 · Emlyn Roberts · John Gittins · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Andrew Collins · 2 Oct 2018
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
Later · Emlyn Roberts · 6 Jul 2023
“the delay in the attendance of the ambulance is significant and unacceptable.”
What happened next
No web check of the stated actions has been published for this chain.