“Entry into Hospital and Delay to bed allocation 1”
Dated 18 Jul 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
Deadline passedReplies were due by 12 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 dated18 Jul 2023
- Deadline12 Sep 2023
- Published on judiciary.uk21 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 12 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” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 12 Sep 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
– Entry into Hospital and Delay to bed allocation 1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED). 2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day. 3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23. Care Concerns in the ED 4. On 18.03.2 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas. 5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN | 6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician. 7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23. 8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him. Staffing 9. There were insufficient nursing and clinical staff to attend to the numbers of patients as outstanding nursing shifts went unfulfilled on the nursing rota. 10. Due to the presenting circumstances, staff were unable to fulfil their role in caring for Mr Hawkins. 11. Specifically, I am concerned as to the wait and delay Mr Hawkins had to endure to enter hospital and the same in respect of being provided with a bed; the inability of staff to tend to him; the lack of available staff and the lack of written record of assessment and treatment.
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, 2023-0248
- 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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