“This is a further Report, of several by me, as both Senior Coroner for North West Wales…”
Dated 10 Jul 2023, from the coroner for North West Wales. 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 4 Sep 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 dated10 Jul 2023
- Deadline4 Sep 2023
- Published on judiciary.uk18 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 4 Sep 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” | Response publishedPublished on judiciary.uk in July 2023. |
| North Wales Local Authorities | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 4 Sep 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still 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.
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, 2023-0236
- 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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