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recurance

Ester Wood

6 Jun 2018 · Coroner David Pojur · North Wales (East and Central)

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. ambulance delays and admission to ED

    “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 this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of [name redacted].”
  2. 2. patient flow issues

    “patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of [name redacted].”

Linked reports

Repeats an earlier warningPamela Conway26 Aug 2016 · 1 year 9 months earlier
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”
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 this Court on several occasions”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningLilly Baxandall17 May 2017 · 1 year 1 month earlier
Closely relatedConfidence 0.90 · high

Earlier report

“substantial delays in the handover of patients particularly as a result of problems in patient flow”
Original on judiciary.uk ↗

This report

“patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions”
Full chain: Patient flow problems leading to ambulance handover delays

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