Diane Greenslade
21 Dec 2018 · Coroner Wendy James · Gwent
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of initial contact and clinical assessment
“The initial call was categorised Green 3 without any contact being made with Mrs [name redacted] or her family and without any clinical assessment”
2. failure to upgrade call category or request police welfare check
“After failing to make contact, no consideration was given to either upgrading the call category or to contacting the Police to ask them to carry out a welfare check”
3. high ambulance demand and hospital delays
“Demand for ambulances was high compounded by excessive delays at hospitals”
4. rapid response vehicle ring-fenced for higher priority calls
“A rapid response vehicle had been based only eight minutes away from Mrs [name redacted] home since at least 6.30 and had not responded to any calls as it was ring fenced for red and amber 1 calls”
5. delay in medical intervention contributing to death
“The delay in medical intervention must have played a significant role in Mrs [name redacted] death”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“Demand for ambulances was high compounded by excessive delays at hospitals.”
Later report
“the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital.”
Responses
2018-0401-Response-by-University-Health-Board.pdf ↗· Aneurin Bevan University Health Board
Stated action · weekly
“The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board's Executive Team each week.”
2018-0401-Response-by-Welsh-Ambulance-Services.pdf ↗· Welsh Ambulance Service