Daphne Williams
25 May 2017 · Coroner John Gittins · North Wales (East and Central)
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. ambulance delays and admission to emergency department
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
This report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow”
Identical hazardConfidence 0.96 · high
This report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.”
Later report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.”
Identical hazardConfidence 0.90 · high
This report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.”
Later report
“Following an inquest which concluded in January 2014 | issued a regulation 28 report in which | expressed concerns regarding the handover of patients at an emergency department which resulted in”
Closely relatedConfidence 0.90 · high
This report
“ambulance delays/admission to ED/availability of resources/patient flow”
Later report
“unacceptably lengthy delays remain such as in the case of [the deceased]”
Responses
2017-0167-Response-by-University-Health-Board.pdf ↗· Betsi Cadwaladr University Health Board
Stated action · October 2015
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”