Gladys Williams
PFD Report
Historic (No Identified Response)
Ref: 2018-0292
Coroner's Concerns (AI summary)
Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.
View full coroner's concerns
_ The issues of ambulance delaysladmission to EDlavailability of resourceslpatient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which | am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems Coroncr'$ Office, County Hall, Wynnstay Road, Ruthin, LLIS IYN Tcl 01824 708047 Fax 01824 708048 for Frailty day: being busy and continue to believe and be extremely concerned that patients' lives are being placed at risk as a result: Whilst it no longer appears to be the case that problems of this nature can be attributed to "winter pressures' it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
Sent To
- Betsi Cadwaladr University Health Board
- Welsh Ambulance Services
Response Status
Linked responses
0 of 2
56-Day Deadline
15 Mar 2019
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 the25ih of April 2018 commenced an investigation into the death of Gladys May Williams (DOB 11.1.25 DOD 24.4 The investigation concluded at the end of the inquest on the 6th of September 2018. The conclusion of the inquest was one of an accidental death the Cause of Death being recorded as 1(a) Aspiration Pneumonia 2 with Fracture of Cervical Spine
Circumstances of the Death
On the 6th of March 2018 the Deceased fell at her care home and was taken to the Wrexham Maelor Hospital where she was examined and subsequently discharged the same She continued to be unwell and an ambulance was called again at 21.21 following examination by the Out of Hours doctor Due to her continuing deterioration a further call was made to the ambulance service at 04.01 on the 7th of March however no ambulances were available and an ambulance did not arrive until 07.10. Thereafter the ambulance left the scene at 07.41arriving at the Emergency Department of the Maelor Hospital, Wrexham at 07.55. Due to the department her care was not handed over to hospital staff until 09.27 more than twelve hours after the original call from her care home which is less than fifteen minutes' drive from the hospital although it cannot be said that this delay contributed to her death.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.