Joseph Cattle
22 Feb 2024 · Coroner Gavin Knox · South Wales Central
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance dispatch
“Welsh Ambulance Service Trust were unable to allocate an available ambulance resource in an Amber 1 category call until over 6 hours from the time of the 999 call”
2. ambulance handover delays
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals”
3. insufficient ambulance resources
“The number of funded ambulances appeared to be significantly short of what would have been needed in the circumstances”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes.”
This report
“Welsh Ambulance Service Trust were unable to allocate an available ambulance resource in an Amber 1 category call until over 6 hours from the time of the 999 call;”
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.”
This 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;”
Closely relatedConfidence 0.90 · high
This 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;”
Later 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,”
Identical hazardConfidence 0.90 · high
This 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;”
Later 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.”
Responses
2024-0107-Response-from-Welsh-Government.pdf ↗· Welsh Government
Stated action
“I have directed each LHB to develop a local 'six goals' programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities.”