Ronald Hamer
20 Apr 2016 · Coroner Graeme Hughes · South Wales Central
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance arrival
“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”
2. lack of follow-up communication
“Cognisant of the delay in responding to the original call to the emergency "| services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call”
3. systemic service failure
“The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the an February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr [name redacted] could repeat themselves”
Linked reports
Closely relatedConfidence 0.90 · high
This 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.”
Later report
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
Closely relatedConfidence 0.85 · high
This 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.”
Later 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;”
Responses
2016-0149-Response-by-Welsh-Ambulance-Services-NHS-Trust.pdf ↗· Welsh Ambulance Service NHS Trust
Stated action · 9 June 2016
“Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”