Skip to content
recurance

Sylvia Evans

20 May 2024 · Coroner Caroline Saunders · Gwent

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. delayed ambulance response

    “[the deceased] suffered an injury to her leg which caused extensive blood loss. At 22:56 hours she called for an ambulance. The call ended abruptly, and the inquest determined that [the deceased] was bleeding heavily and suffering the effects of heart failure exacerbated by severe haemorrhage, which caused her to end the call. The nature of her injuries had not been conveyed to the call handler.”

Linked reports

Repeats an earlier warningAlyn Rees9 Sept 2020 · 3 years 8 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“However, the famHy raised concerns, with which I agreed, that 2 hours is a long time I I to wait for an _emergency ambulance.”
Original on judiciary.uk ↗

This report

“An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered.”
Full chain: Delayed ambulance handover leading to unavailability

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error