“Whilst there was no direct evidence at the inquest to establish whether or not the…”
Dated 6 Jul 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 31 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 dated6 Jul 2023
- Deadline31 Aug 2023
- Published on judiciary.uk7 Jul 2023
- Today23 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 31 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 31 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 31 Aug 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN | It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community). I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
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, 2023-0229
- 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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