Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0229, written 6 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jul 2023 |
|---|---|
| Reference | 2023-0229 |
| Deceased | Emlyn Roberts |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Wales prevention of future deaths reports (2019 onwards) · Emergency services related deaths (2019 onwards) |
| 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.
John Gittins
Senior Coroner for North Wales (East and Central)
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust
(WAST), North Wales Local Authorities
CORONER
I am John Gittins, Senior Coroner for North Wales (East and Central)
CORONER’S LEGAL POWERS
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 the 17th March 2022 an investigation was commenced into the death of Emlyn
Victor Roberts (DOB 09/05/48) who died at his home on the 14th March 2022. The
investigation concluded at the end of the inquest on 5th of July 2023. The conclusion of
the inquest was that the death was due to natural causes, namely 1(a) Left Sided
Intrathoracic Haemorrhage (b) Ruptured Dissecting Aneurysm of the Arch of the Aorta
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are that at 20.01 on the 13th of March 2022, the deceased
called an ambulance complaining of a sudden onset of pain and trouble breathing. He made a
further call at 00.20 but due to an absence of available resources, an ambulance was unable to
attend for a further seven hours at 07.27 on the morning of the following day, when he was
found deceased at his home. In total there was a delay of almost eleven and a half hours from
the initial call for help.
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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. –
Whilst there was no direct evidence at the inquest to establish whether or not the
outcome may have been different if Mr Roberts had received earlier medical care and
attention, the delay in the attendance of the ambulance is significant and
unacceptable.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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It is recognised that the reasons for such delay are multifactorial and both I and my
Assistant Coroners have issued multiple previous reports for the prevention of future
deaths expressing similar concerns. One of my earliest such reports expressing concern
regarding ambulance response times, was in relation to a death in March 2013 and yet
more than ten years later this problem has become significantly worse rather than
better.
It is understood that the matter of ambulance delays is not solely a matter for WAST
hence this report being sent to those organisations involved in its impact across the
Health Board area (to include the provision of social care where patients are medically
fit for discharge from hospitals but without adequate placements / care in the
community).
I remain significantly concerned not only that delays are continuing and that deaths will
continue to occur into the future, but also that there is inadequate cohesive forward
thinking or planning either in relation short term pressures (eg. winter pressures) or
with a view to finding longer term solutions.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely 31st August 2023. I, John Gittins, the Coroner, may extend the period.
I would be prepared to accept a joint response from all organisations.
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.
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COPIES and PUBLICATION
I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner.
I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her
information.
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 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 release or the publication of your response by the Chief
Coroner.
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Dated 6th July 2023
Signature
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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