Jeanette Sidlow Beech
29 May 2025 · Coroner Kate Robertson · North Wales (East and Central)
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. ambulance delay
“It took a total period of 15 hours and 13 minutes for an ambulance to attend upon [the deceased], by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.”
2. hospital handover delay
“Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.”
3. lack of social care and community hospital beds
“It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours.”
4. ongoing ambulance delay risk to life
“There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays”
This report
“It took a total period of 15 hours and 13 minutes for an ambulance to attend upon [the deceased], by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.”
Identical hazardConfidence 0.90 · high
Earlier report
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
This report
“Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.”
Closely relatedConfidence 0.90 · high
Earlier report
“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”
This report
“It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged”
Responses
2025-0279-Response-from-Welsh-Government-.pdf ↗· Welsh Government
Stated action · quarter three in 2025-26
“All health boards are required to implement the ambulance patient handover guidance - it is one of the five key priorities ('enabling actions') for urgent and emergency care within the NHS Planning Framework for 2025-26 and has been incorporated into the performance criteria for all health board chairs.”