“5 The investigation focused upon the causal significance, if any, of a delay of some…”
Dated 15 Nov 2023, from the coroner for South Wales 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 14 Feb 2024, after the 56 days for replies had ended (10 Jan 2024). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated15 Nov 2023
- Deadline10 Jan 2024
- Published on judiciary.uk14 Feb 2024
- 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 Service NHS Trust” | Response publishedPublished on judiciary.uk in February 2024. |
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in February 2024. |
| Department of Health and Social Care | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
5 The investigation focused upon the causal significance, if any, of a delay of some thirteen hours, or thereabouts in the provision of an ambulance to the deceased. I received written & oral evidence from Andrew Garner of the Welsh Ambulance Service Trust (I annex a copy of his witness statement). I refer you in particular, to paragraph’s 43-49. My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital. As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016. Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
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, 2024-0069
- 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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