“The ongoing pressures faced by the ambulance service are clearly multifactorial”
Dated 20 Jan 2023, from the coroner for Gwent. Sent to 2 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 17 Mar 2023. 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 dated20 Jan 2023
- Deadline17 Mar 2023
- Published on judiciary.uk24 Jan 2023
- Today23 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 NHS Trust” | Response publishedPublished on judiciary.uk in January 2023. |
| Department of Health and Social Care | 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
1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent, where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients. 2. The Amber 1 category includes all life-threatening conditions except those in the Red category where the person appears to be in the throes of dying. I was informed that all the patients in the Amber 1 category are allocated an ambulance / clinical resource chronologically, without further consideration of clinical need. 3. I was informed at the inquest that on occasion a clinician within WAST will intervene to undertake a further assessment to determine whether the response should be expedited. However, this appeared to be an ad hoc arrangement not underpinned by local policy or guidelines. 4. The evidence suggested that a patient who was choking, had difficulty breathing and was drowsy would still be assessed, under the current algorithm adopted by WAST, as meeting the requirement for an Amber 1 response.
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, 2023-0020
- 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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