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recurance

Margaret Evans

26 Jun 2018 · Coroner John Gittins · North Wales (East and Central)

This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. ambulance delays and admission to emergency department

    “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”

Linked reports

Repeats an earlier warningPamela Conway26 Aug 2016 · 1 year 10 months earlier
Identical hazardConfidence 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”
Original on judiciary.uk ↗

This 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.”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningLilly Baxandall17 May 2017 · 1 year 1 month earlier
Identical hazardConfidence 0.93 · 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

“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”
Full chain: Ambulance handover delays due to bed shortages
Raised again laterMadeline Staples11 Feb 2019 · 8 months later
Identical hazardConfidence 0.90 · high

This 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.”

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”
Original on judiciary.uk ↗
Full chain: Ambulance handover delays due to bed shortages

Responses

No published response was found on judiciary.uk.

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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