Ceriann Richards
1 Mar 2017 · Coroner Andrew Barkley · South Wales Central
A similar concern from this report was raised again 5 times later. See the linked reports.
The coroner's concerns
1. ambulance dispatch delay
“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 within the Aneurin Bevan University Health Board Areas which on that day for the Royal Gwent Hospital were of an average of 107 minutes up to a maximum of 279 minutes and for the Neville Hall Hospital with an average delay of 43”
2. report response deadline
“the coroner, may extend the period”
3. toxic medication levels
“A subsequent post mortem examination revealed that she had toxic levels of prescribed anti-depressant medication Venl”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
Later report
“On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”
Closely relatedConfidence 0.90 · high
This report
“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 report
“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.”
Identical hazardConfidence 0.90 · high
This report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
Later report
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
Identical hazardConfidence 0.90 · high
This report
“(1) The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
Later report
“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”
Identical hazardConfidence 0.90 · high
This report
“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”
Later report
“It took a total period of 15 hours and 13 minutes for an ambulance to attend upon [the deceased], by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.”
Responses
2017-0041-Response-by-University-Health-Board.pdf ↗· Neville Hall Hospital
Stated action · 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”
2017-0041-Response-by-Welsh-Government.pdf ↗· Welsh Government
Stated action
“We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service's ability to respond to subsequent calls in the community, but also on patient's experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital”