Margaret Evans
PFD Report
Historic (No Identified Response)
Ref: 2018-0197
Coroner's Concerns (AI summary)
Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
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 continue to the present and patients' lives are placed at risk as a result: Coroner'= Office; County Hall, Wynnstay Road, Ruthin, LLIS IYN Tel 01824 708047 Fax 01824 708048 for the being day being
Sent To
- BCUHB
- Welsh Ambulance Services NHS Trust
Response Status
Linked responses
0 of 4
56-Day Deadline
21 Aug 2018
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 the 6th of February 2018 commenced an investigation into the death of Margaret Megan Evans (DOB 28.12.24 DOD 5.2.18) The investigation concluded at the end of the inquest on the 22nd of June 2018_ The conclusion of the inquest was one of an accidental death the Cause of Death being recorded as 1(a) Hospital Acquired Pneumonia 2. Fractured Neck of Femur
Circumstances of the Death
On the 22nd of January 2018 the Deceased fell outside her home and sustained a fractured hip as a result; An ambulance was summonsed to assist her at 10.32 however no ambulances were available and an ambulance did not arrive until 13.51. Thereafter the left the scene at 14.25 arriving at the Emergency Department of the Maelor Hospital, Wrexham at 14.51_ Due to the department busy she was not brought in until 21.22 and was seen by the consultant at 21.28 As a consequence of the above the Deceased had to endure more than three hours lying on a concrete path and was not seen by the ED doctor until almost eleven hours after help was initially summonsed although it cannot be said that these delays 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.