Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0190, written 9 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Sep 2020 |
|---|---|
| Reference | 2020-0190 |
| Deceased | Alyn Rees |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Emergency Services related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Organisation named | Welsh Ambulance Services NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
egulations 28 and 29 of the Coroners (Investigations} Regulations 2013 lEGULA1\0N 28: REPOR1TO PREVENT FUTURE DEATHS REGULAT\ON 28 REPORT TO PREVENT FUTURE DEATHS TH\S REPORT \S BEING SENT TO: \ 1. Welsh Ambulance Services NHS Trust (WAST) 2. Aneurin Bevan University Health Board (ABUHB) \ CORONER t am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER1 S LEGAL POWERS 2 3 I 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 10 December 2019 I commenced an investigation into the death of Alyn Lewis Rees, DOB: 3/10/1990 The investigation concluded at the end of the inquest on 26/8/2020 The conclusion of the inquest was recorded as Natural Causes The medical cause of death was Disseminated Lymphoma 4 CIRCUMSTANCES OF THE DEATH On 3rd December 2019 Alyn Rees became acutely unwell and an ambulance was called' at 12:19 hours. This was the first of 6 calls. Mr Rees was experiencing breathing difficulties and he had been informed by his GP at a recent attendance that he may be suffering from a pulmonary embolism although that diagnosis had not been formally made. ·Mr Rees was designated an Amber 1 status by WAST During the final phone call Mr Rees deteriorated and went into cardiac arrest. His status was changed to a Red Call. Sadly when the paramedics arrived at 14:17, he could not be revived and his death was confirmed at 14:39. At post mortem examination it was determined that Mr Rees died from widespread disseminated lymphoma. 5 CORONER'S CONCERNS :.. ~- '"bu"rmg'tfte cours~b~ttle·,ntttte I ·e ffl ' .. -~ &tllJ!Sfll~~Jr.'JJ~ 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: - During the-inquest I referred to a report from WAST which described the assessment process. I am of t~e opinion that the assessment made and the status afforded to Mr Rees throughout was correct and no criticism was made of this. '\ . However, the famHy raised concerns, with which I agreed, that 2 hours is a long time to wait for an _emergency ambulance. At no time were the family advised of the expected time:of arrival and potentially, if they had been aware of this, they may have contacted e.arlie,rthe local GP. The report did, no·~ in~icate what the expected response time for an Amber 1 call should be. · · ... ·.. .1.' ·1, I I I I I I I I I I I I I l I I I I I I I I I I I I I I I I I I I I I I I was advised:thaf'on·this occasion there were significant delays (up to 3 hours) transferring pat~~~ts_ into the care of Aneurin Bevan University Heath Board Hospitals. This is also of sigh1ficant concern as it prevented emergency ambulances being released. . . ·.-·:·. ·. . :, .•· .. ' I .. . • 1 I should emphasise that I do not consider that in this case Mr Rees' life would have been saved if f.ie t,Jad received medical attention earlier. He was (quite unbeknownst to him) suffering. f rom a widespread lymphoma which presented acutely on the day he died. . ···1 , , ,,, · . 6 7 YOUR RESPONSE I 'lou are under a duty to respond to this report within 56 days of the date of this report. \, the Coroner, may extend this period Your response must contain details of action taken or proposed to be taken, setting out the timetab\e for action. Otherwise you must explain why no action is necessary \ 8 COPIES AND PUBLICATION \ have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Mr Alyn Rees I am 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 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 release or the publication of your response by the Chief coroner. 9 DATE 9/9/2020 Signed
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