In February 2019 issued a regulation 28 report to BCUHB in which expressed the following concerns Coroncr'$ Ollice; County Hall; Wynnstay Road Ruthin. LLIS HIN Tcl 01824 708047 Fax 01824 708048 To and

"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 "unacceptable delays with patients kept waiting for long periods in ambulances and ambulance resources consequently unavailable for allocation to other calls" In the intervening period from then until the present either or my Assistant Coroners have issued at least twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is taken to reduce such delays, the situation continues t0 prevail: As has been stated previously in my other reports, | recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable. Notwithstanding the fact that Mr Connelly's death preceded the said February 2019 report and that there has been a reduction in the number of hours which ambulances were kept waiting outside ED since his death, the evidence which heard at his inquest informed me that the ED at the Maelor Hospital, Wrexham continues to operate under extreme pressures and at an average scale of escalation (namely 3.1) which consider is a clear indication that the various factors which cause delays in admission to hospital, have not been eliminated. Consequently it remains the case that delays in treatment may occur along with deaths which should be preventable by timely medical intervention_