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recurance

Catherine Roberts

7 Jul 2017 · Coroner Nicola Jones · North Wales (East and Central)

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

The coroner's concerns

  1. 1. admission to the Emergency Department without adequate resources

    “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.”

Linked reports

Repeats an earlier warningPamela Conway26 Aug 2016 · 10 months earlier
Closely relatedConfidence 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”
Original on judiciary.uk ↗

This report

“The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests”
Full chain: Ambulance delays leading to resource unavailability
Raised again laterGladys Williams10 Sept 2018 · 1 year 2 months later
Closely relatedConfidence 0.90 · high

This report

“The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.”

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”
Original on judiciary.uk ↗
Full chain: Ambulance delays leading to resource unavailability

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