Dorothy Jones
20 Jan 2023 · Coroner Caroline Saunders · Gwent
The coroner's concerns
1. failure to provide a resource within a reasonable timeframe
“The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent, where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for”
2. allocation of ambulance based on chronological order without clinical need assessment
“The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need”
3. ad hoc clinician intervention for expedited response lacking policy
“I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited. However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines”
4. misclassification of critical symptoms as Amber 1
“The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed, under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response”