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recurance

David Strachan

20 Feb 2023 · Coroner Kate Sutherland · North Wales (East and Central)

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. ambulance delay

    “all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites”

Linked reports

Repeats an earlier warningRebecca Evans14 Mar 2017 · 5 years 11 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
Original on judiciary.uk ↗

This report

“there were significant handover delays across all BCUHB sites.”
Full chain: Inadequate patient handover practices
Repeats an earlier warningLilly Baxandall17 May 2017 · 5 years 9 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Original on judiciary.uk ↗

This report

“he causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.”
Full chain: Ambulance delays leading to resource unavailability

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error