Raymond Gillespie
PFD Report
Historic (No Identified Response)
Ref: 2022-0154
Coroner's Concerns (AI summary)
Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.
View full coroner's concerns
(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
Sent To
- Welsh Ambulance NHS Foundation Trust and Betsi Cadwaladr University Local Health Board
Response Status
Linked responses
0 of 1
56-Day Deadline
20 Jul 2022
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 4.11.22, an investigation was commenced into the death of Raymond Gillespie. The investigation concluded at the end of an Inquest on 24 May 2022. The conclusion of the inquest was :- Natural causes contributed to by a fall The medical cause of death was 1a. frailty of old age, dementia, chronic kidney disease
2. Acute on chronic kidney disease, fractured neck of right femur (non-operated)
2. Acute on chronic kidney disease, fractured neck of right femur (non-operated)
Circumstances of the Death
These were recorded as :- Raymond Gillespie was a care home resident suffering from a number of comorbidities. On 8 October 2021 he suffered an unwitnessed fall. Welsh Ambulance Service Trust (WAST) were contacted at 21.59 due to hip pain and potential fracture. An initial response of 6 hours was provided for response (health care professional category, extended from 4 due to resource issues). Several welfare checks were conducted throughout the night by WAST. The following day at 11.40 a further 999 call was made by the care home as there was still no WAST attendance. At 12.57 a paramedic arrived, some 14 hours and 58 minutes following the initial call.
Copies Sent To
and the Health Inspectorate Wales
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.