“Sylvia Evans suffered an injury to her leg which caused extensive blood loss”
Dated 20 May 2024, from the coroner for Gwent. 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 15 Jul 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 dated20 May 2024
- Deadline15 Jul 2024
- Published on judiciary.uk23 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
Sylvia Evans suffered an injury to her leg which caused extensive blood loss. At 22:56 hours she called for an ambulance. The call ended abruptly, and the inquest determined that Sylvia was bleeding heavily and suffering the effects of heart failure exacerbated by severe haemorrhage, which caused her to end the call. The nature of her injuries had not been conveyed to the call handler. The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people wo are likely to be suffering from a lifethreatening emergency. An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylivia had died by the time the ambulance arrived. 6 The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
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, 2024-0275
- 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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