_ 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 t0 other calls Coroner'$ Office; County Hall; Wynnstay Road_ Ruthin; LLIS AYN Tel 01824 708047 Fax 01824 708048 delay being being being

In the intervening period from then until the present either or my Assistant Coroners have issued at least a further twelve similar 'regulation 28 reports expressing concerns associated with unacceptable delays and yet despite given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to 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_