“Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN | The Trust utilises the…”
Dated 12 Sep 2023, from the coroner for North Wales (East and Central). Sent to 1 organisation or person.
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 7 Nov 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 dated12 Sep 2023
- Deadline7 Nov 2023
- Published on judiciary.uk15 Sep 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Services NHS Trust” | Response publishedPublished on judiciary.uk in September 2023. |
The coroner’s concerns
– Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN | The Trust utilises the Medical Priority Dispatch System (MPDS) and there are specific instructions within the same in relation to a varicose vein bleed namely “Elevate the affected leg/arm (above heart level on a cushion pillow or other soft object” Although from the outset this was recognised to be a varicose vein bleed, this advice was not given in at least two of the first four calls due to human error and it appears from the evidence that until the 5th call was made at 20.04, that no such clinically beneficial advice was given to those family members who were attending to the deceased. Evidence was provided that a memo/reminder had been issued to staff regarding this error, however there was no evidence as to the effectiveness of such a reminder in the reduction of human error and I am concerned that deaths may occur as a result of failures to provide advice available within MPDS due to handlers not following the correct/most appropriate pathway.
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, 2023-0325
- Added to Minute Book
- 8 Oct 2026
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- 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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