“[BRIEF SUMMARY OF MATTERS OF CONCERN) (1) ‘Demand analysis’ seriously underestimated the…”
Dated 30 Jul 2018, from the coroner for South Wales Central. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 24 Sep 2018. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated30 Jul 2018
- Deadline24 Sep 2018
- Published on judiciary.uk24 Sep 2018
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Service Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Minister for Health | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Cardiff and Vale University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— [BRIEF SUMMARY OF MATTERS OF CONCERN) (1) ‘Demand analysis’ seriously underestimated the number of ambulances required in Cardiff and the Vale that night. Evidence showed that only 7 ambulances were available up until 2am, then 5 available up until 3am. Also 7 hours of ambulance time was lost during the period 02:26 — 06:30 due to delays at A&E. (2) There does not seem to be a reliable system for the making and cha: “welfare calls’. \g-up of Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident. (3) The target turnaround time for ambulances at A&E is wildly unrealistic. Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes. Such delay must have a knock-on effect upon the ‘demand analysis’. (4) The police could have been asked to perform a welfare check. Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2018-0249
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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