Mary Jones
PFD Report
Partially Responded
Ref: 2023-0236
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
1 of 2 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
4 Sep 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
Responses
The Welsh Ambulance Services NHS Trust is working closely with Health Boards and the Welsh Government to develop a coherent set of sustainable solutions to address ambulance delays and patient offload issues. They also regularly review existing plans, such as the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, at their Trust Board.
AI summary
View full response
Dear Ms Robertson
Re: Mrs Mary Elizabeth Jones
I write in response to the Prevent of Future Deaths Report issued to this Trust on the 10 July 2023, following the inquest. Firstly I would like to apologise for the delay in responding to you in relation to this matter. Also, can I please pass on apologies from , Assistant Director of Quality and Nursing Directorate.
The matters of concern that you have asked the Trust to consider are:-
This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
2 I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local Government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.
The Trust has previously shared with you that it is represented on the North Wales Regional Partnership Board, which brings together a range of statutory and non-statutory partners, including Local Authority representation at both officer and member level, focused on improving collaborative services provided to the people of North Wales, including older people.
The Trust has evidenced this work through the comprehensive details of all the actions that we have taken to date, and I have also shared with you the measures that are currently in place, such as the Clinical Safety Plan and the Regional Escalation Action Plan. I have not attached copies of these Plans again, as I have previously supplied them.
I have shared with you copies of the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, both of which were presented to the Public Trust Board on the 27 July 2023. This Report is regularly presented to, and reviewed by, the Trust Board and I hope this offers you assurance that this matter continues to remain a significant risk and a matter of attention to the full Trust Board.
While the Trust fully supports the need to issue a Report under Paragraph 7, Schedule 5, of the Coroners & Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, we do not believe that we are the authority with the “power to take such actions”. Therefore, I respectfully request your consideration as to any further actions you feel the Trust could take, over and above those we have already shared with you. Equally, I would genuinely welcome any suggestions you may have regarding actions we might take or seek to take with our partners.
To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.
While writing I would again like to offer my sincere condolences to Mrs Jones’s family on their sad loss. I would like to extend the offer to meet with you and leaders of other key organisations to discuss our response in more detail, and to provide you with any further assurances you may require regarding our commitment to continued improvement to support the prevention of harm and future deaths.
Re: Mrs Mary Elizabeth Jones
I write in response to the Prevent of Future Deaths Report issued to this Trust on the 10 July 2023, following the inquest. Firstly I would like to apologise for the delay in responding to you in relation to this matter. Also, can I please pass on apologies from , Assistant Director of Quality and Nursing Directorate.
The matters of concern that you have asked the Trust to consider are:-
This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
2 I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local Government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.
The Trust has previously shared with you that it is represented on the North Wales Regional Partnership Board, which brings together a range of statutory and non-statutory partners, including Local Authority representation at both officer and member level, focused on improving collaborative services provided to the people of North Wales, including older people.
The Trust has evidenced this work through the comprehensive details of all the actions that we have taken to date, and I have also shared with you the measures that are currently in place, such as the Clinical Safety Plan and the Regional Escalation Action Plan. I have not attached copies of these Plans again, as I have previously supplied them.
I have shared with you copies of the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, both of which were presented to the Public Trust Board on the 27 July 2023. This Report is regularly presented to, and reviewed by, the Trust Board and I hope this offers you assurance that this matter continues to remain a significant risk and a matter of attention to the full Trust Board.
While the Trust fully supports the need to issue a Report under Paragraph 7, Schedule 5, of the Coroners & Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, we do not believe that we are the authority with the “power to take such actions”. Therefore, I respectfully request your consideration as to any further actions you feel the Trust could take, over and above those we have already shared with you. Equally, I would genuinely welcome any suggestions you may have regarding actions we might take or seek to take with our partners.
To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.
While writing I would again like to offer my sincere condolences to Mrs Jones’s family on their sad loss. I would like to extend the offer to meet with you and leaders of other key organisations to discuss our response in more detail, and to provide you with any further assurances you may require regarding our commitment to continued improvement to support the prevention of harm and future deaths.
Report Sections
Investigation and Inquest
On 19 January 2023 an investigation was commenced into the death of Mary Elizabeth Jones (DOB 30/12/36) who died on 14 January 2023. The investigation concluded at the end of the inquest on 7 July 2023. The conclusion of the inquest was that Mary Elizabeth Jones had died from natural causes contributed to by a fall.
Circumstances of the Death
The circumstances of the death are as follows :- On Sunday 4th December 2022 at around 10am Mary Elizabeth Jones had an unwitnessed fall at home. An ambulance was called which arrived 26 hours and 23 minutes later. She was taken to Ysbyty Gwynedd. She remained on the back of the ambulance due to Emergency Department pressures for a further 8 hours and 23 minutes. She was assessed by a doctor on the back of the ambulance at around 8pm on 5th December. CT scan of her pelvis identified an undisplaced fracture. She deteriorated on 17 December 2022 with low blood pressure and abdominal tenderness and a new oxygen requirements and was receiving antibiotics for a suspected urinary tract infection. By early January 2023 a further deterioration was noted – she was drowsy and eating less and her blood tests showed a drop in haemaglobin. She had a blood and iron tranfusion. An abdominal bleed was diganosed on 6th Janaury and she had a poor prognosis. Palliative care was commenced and she sadly passed away on 14 January 2023 certified at 18:00 hours at Ysbyty Gwynedd.
Coroner's Office, Shirehall Street, Caernarfon
Coroner's Office, Shirehall Street, Caernarfon
Copies Sent To
Coroner's Office, Shirehall Street, Caernarfon
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.