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recurance

Angela Darlow

5 Feb 2026 · Coroner Kate Robertson · North Wales (East and Central)

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. delayed ambulance arrival

    “[the deceased] was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend.”
  2. 2. missed window for thrombectomy

    “She was diagnosed with an extensive left middle cerebral artery infarct. Given the passage of time she was not suitable for investigations and thrombectomy. She instead received antiplatelets and was admitted to the stroke ward. She remained stable and was transferred to Mold Communty Hospital on 7 March 2025 with a poor prognsis. She died from the effects of the stroke at hospital on 7 June 2025.”
  3. 3. preventable deaths

    “People are dying due to these issues and yet we are no closer to improvement.”

Linked reports

Repeats an earlier warningAndres Roberts23 Sept 2020 · 5 years 4 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival.”
Original on judiciary.uk ↗

This report

“Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend.”
Full chain: Delayed access to acute stroke treatment

Responses

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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

Angela Darlow · Recurance