“There was evidence from WAST and BCUHB that improvements had been made internally within…”
Dated 21 Jun 2023, from the coroner for North Wales (East and 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 16 Aug 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 dated21 Jun 2023
- Deadline16 Aug 2023
- Published on judiciary.uk23 Jun 2023
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Aug 2023. A reply may have been sent and not yet published. |
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Service Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Aug 2023. A reply may have been sent and not yet published. |
| North Wales Local Authorities | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Aug 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following:1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and 3. Extent of Strategic plan of action / improvement plan to address the above 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, 2023-0203
- 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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