“There was a significant delay in getting an ambulance to Jean which resulted in a…”
Dated 4 Mar 2024, from the coroner for Swansea Neath and Port Talbot. 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
All responses publishedReplies were due by 29 Apr 2024.
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 dated4 Mar 2024
- Deadline29 Apr 2024
- Published on judiciary.uk14 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Swansea Bay University Health Board | Response publishedPublished on judiciary.uk in March 2024. |
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Service” | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
– 1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be offloaded into hospital. The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes,
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, 2024-0121
- 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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