“[he causes of the ambulance delay were that all available resources were managing…”
Dated 20 Feb 2023, from the coroner for North Wales (East and Central). 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
All responses publishedReplies were due by 17 Apr 2023.
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; a reply may have been sent and not yet published.
- Report dated20 Feb 2023
- Deadline17 Apr 2023
- Published on judiciary.uk27 Feb 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in February 2023. |
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance NHS Trust” | Response publishedPublished on judiciary.uk in February 2023. |
The coroner’s concerns
- [he causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were lsignificant handover delays across all BCUHB sites. The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in brder to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed !ambulance attendances caused by these multifactorial issues.
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, 2023-0065
- 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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