“There was a significant delay in getting an ambulance to Peter which resulted in him…”
Dated 22 Oct 2024, from the coroner for Swansea Neath and Port Talbot. 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
All responses publishedReplies were due by 17 Dec 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 dated22 Oct 2024
- Deadline17 Dec 2024
- Published on judiciary.uk22 Oct 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Swansea Bay University Health BoardNamed in the report as “SWANSEA BAY UNIVERSITY HEALTH BOARD” | Response publishedPublished on judiciary.uk in October 2024. |
| Welsh Ambulance Services University NHS TrustNamed in the report as “WELSH AMBULANCE SERVICE NHS TRUST” | Response publishedPublished on judiciary.uk in October 2024. |
| WELSH ASSEMBLY GOVERNMENT | Response publishedPublished on judiciary.uk in October 2024. |
The coroner’s concerns
– 1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 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, 2024-0565
- 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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