Pamela Conway
26 Aug 2016 · Coroner John Gittins · North Wales (East and Central)
This report repeats 1 earlier warning, and was raised again 12 times later. See the linked reports.
The coroner's concerns
1. patients kept waiting in ambulances
“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”
2. patient flow delays in Emergency Department
“patient flow' within the Maelor Hospital continues to result in delays within the Emergency Department”
3. previous regulation 28 reports and ongoing inquests
“such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
This 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”
Identical hazardConfidence 0.90 · high
This 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”
Later report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Identical hazardConfidence 0.90 · high
This report
“there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
Later report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow”
Closely relatedConfidence 0.90 · high
This 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”
Later 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”
Identical hazardConfidence 0.90 · high
This 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”
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 this Court on several occasions”
Identical hazardConfidence 0.90 · high
This report
“That notwithstanding changes which have been made by both BCuHB and WAST, 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”
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.”
Closely relatedConfidence 0.93 · high
This 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”
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.”
Identical hazardConfidence 0.90 · high
This 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”
Later report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Closely relatedConfidence 0.90 · high
This report
“That notwithstanding changes which have been made by both BCuHB and WAST, 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.”
Later report
“Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”
Identical hazardConfidence 0.90 · high
This 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”
Later report
“It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department”
Closely relatedConfidence 0.80 · moderate
This report
“That notwithstanding changes which have been made by both BCuHB and WAST, 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”
Later report
“Evidence was heard at the Inquest that the initial delays experienced by [the deceased] whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty.”
Closely relatedConfidence 0.90 · high
This 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”
Later report
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Responses
2016-0309-Response-by-University-Health-Board.pdf ↗· Betsi Cadwaladr University Health Board
Stated action
“has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”
2016-0309-Response-by-Welsh-Ambulance-Service.pdf ↗· Welsh Ambulance Service NHS Trust
Stated action · 2016-05-05
“we have made progress against key actions which are all identified in the attached action plan”
Conway-2016-0309a.pdf ↗· Betsi Cadwaladr University Health Board