Peter Connelly
7 Nov 2019 · Coroner John Gittins · North Wales (East and Central)
This report repeats 5 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. ambulance delays causing patient deterioration
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Linked reports
Identical hazardConfidence 0.95 · 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
“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
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.”
This 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 0.96 · high
Earlier report
“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
“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
Earlier 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 several occasions following previous inquests.”
This report
“Following an inquest which concluded in January 2014 | issued a regulation 28 report in which | expressed concerns regarding the handover of patients at an emergency department which resulted in”
Identical hazardConfidence 0.96 · high
Earlier report
“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
“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
“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
“unacceptably lengthy delays remain such as in the case of [the deceased].”
Responses
No published response was found on judiciary.uk.