Lilly Baxandall
17 May 2017 · Coroner John Gittins · North Wales (East and Central)
This report repeats 2 earlier warnings, and was raised again 9 times later. See the linked reports.
The coroner's concerns
1. ambulance handover delays
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
2. staff shortages
“excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients”
3. patient flow problems
“substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
4. insufficient beds
“there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”
5. patient flow problems
“there "continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“the 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 and ambulance resources consequently being unavailable for allocation to other calls”
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Identical hazardConfidence 0.90 · high
Earlier report
“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
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Closely relatedConfidence 0.90 · high
This report
“substantial delays in the handover of patients particularly as a result of problems in patient flow”
Later report
“patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions”
Identical hazardConfidence 0.93 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
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”
Closely relatedConfidence 0.90 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
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 0.98 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Identical hazardConfidence 0.96 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Identical hazardConfidence 0.90 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later 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.”
Closely relatedConfidence 0.90 · high
This report
“substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Later report
“I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.”
Identical hazardConfidence 0.92 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Identical hazardConfidence 0.90 · high
This report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Later report
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Responses
2017-0160-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. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”