Leonard Harmsworth
20 Jun 2023 · Coroner Kate Sutherland · North Wales East and Central
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. ambulance arrival and handover delays
“Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. 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.”
2. continuing ambulance delays
“I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.”
3. lack of action on previous reports
“I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“That notwithstanding changes which have been made by both BCuHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.”
This report
“Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. 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.”
Identical hazardConfidence 0.90 · high
Earlier report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
This 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.”
Responses
No published response was found on judiciary.uk.