Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0197, written 26 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2018 |
|---|---|
| Reference | 2018-0197 |
| Deceased | Margaret Evans |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Community health care and emergency services related deaths |
| Organisation named | Welsh Ambulance Services NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins
Senior Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor,
Gwynedd LL57 2PW, Welsh Ambulance Services NHS Trust, HM Stanley Site, St Asaph,
Denbighshire LL17 ORS,
CORONER
tam John Adrian Gittins, Senior Coroner for North Wales (East and Central)
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On the 6" of February 2018 | commenced an investigation into the death of Margaret Megan
Evans (DOB 28.12.24 DOD 5.2.18) The investigation concluded at the end of the inquest on the
22” of June 2018. The conclusion of the inquest was one of an accidental death the Cause of
Death being recorded as 1(a) Hospital Acquired Pneumonia 2. Fractured Neck of Femur
CIRCUMSTANCES OF THE DEATH
On the 224 of January 2018 the Deceased fell outside her home and sustained a fractured hip
as a result. An ambulance was summonsed to assist her at 10.32 however no ambulances were
available and an ambulance did not arrive until 13.51. Thereafter the left the scene at 14.25
arriving at the Emergency Department of the Maelor Hospital, Wrexham at 14.51,
Due to the department being busy she was not brought in until 21.22 and was seen by the
consultant at 21.28.
As a consequence of the above the Deceased had to endure more than three hours lying on a
concrete path and was not seen by the ED doctor until almost eleven hours after help was
initially summonsed although it cannot be said that these delays contributed to her death.
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
The issues of ambulance delays/admission to ED/availability of resources/patient flow and the
multifactorial problems associated with cases of this nature have been reported upon by me on
numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems
continue to the present day and patients’ lives are being placed at risk as a result.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LLIS 1YN
Tel 01824 708047 | Fax 01824 708048
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
218 August 2018 I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner.
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
telease or the publication of your response by the Chief Coroner.
9 Dated 26th June 2018
Signature GAAS
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LLIS 1YN
Tel 01824 708047 {| Fax 01824 708048
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