Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0370, written 22 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2025 |
|---|---|
| Reference | 2025-0370 |
| Deceased | Robyn Chambers |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Child Death (from 2015) · Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (2019 onwards) |
| Organisation named | Welsh Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 18/11/2024 an investigation was opened touching upon the death of Robyn Anne Chambers The investigation concluded at the end of the inquest on 11/7/2025 The conclusion of the inquest was recorded as Natural Causes The medical cause of death was: 1a) Lower Respiratory Tract Infection 1b) Chronic Lung Disease 1c) Extreme Prematurity. Hypoxic Ischaemic Encephalopathy. Epilepsy and Global Developmental delay. 2. Previous Duodenal Perforation. CIRCUMSTANCES OF THE DEATH Robyn Anne Chambers sustained hypoxic ischaemic encephalopathy when she was born prematurely at 23 weeks gestation. This led to significant physical and neurological problems, including ongoing respiratory problems. On 26/10/2024, Robyn developed a chest infection. Despite intensive treatment, the effects were overwhelming and resulted in Robyn’s death on 2/11/2024 at Ty Hafan Hospice in Sully. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - Following Robyn’s traumatic birth she was cared for at home by her parents. Robyn needed extensive medical intervention and monitoring at home. When she became unwell on 26/10/2024 her parents called an ambulance and were informed that it would take about 8 hours for an Amber 1 ambulance to respond. Robyn’s parents decided to take Robyn to hospital themselves which was a difficult and potentially dangerous journey because Robyn had complicated medical equipment that needed to remain attached. The estimated length of time for an ambulance to be dispatched and the decision taken by Robyn’s parents to convey her to hospital had no impact on Robyn’s care and did not affect the outcome. However, having heard evidence from Welsh Ambulance Service NHS Trust, I note that the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital. Evidence provided at inquest indicated that, at the time that Robyn’s parents called for an ambulance, the longest time an ambulance was delayed at the GUH was in excess of 10 hours. 6 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. I am concerned that despite previous assurances that action was being taken by ABUHB and WAST in relation to managing ambulance delays (which I appreciate can be multi-factorial) a significant problem remains in relation to the release of ambulances from the GUH Emergency Department. The handover times are far exceeding the 15-minute handover time agreed between these 2 organisations. Patients’ lives are being, and will continue to be, put at risk if this situation is not resolved. 7 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 16 September 2025. I, the Coroner, may extend this 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 necessary COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Robyn Chambers 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 22/7/25 Signed Caroline Saunders His Majesty’s Senior Coroner for Gwent.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ann Lloyd CBE, Cadeirydd | Chair 01633 435 957 Ann.Lloyd@wales.nhs.uk Nicola Prygodzicz, Prif Weithredwr | Chief Executive 01633 435 958 Nicola.Prygodzicz@wales.nhs.uk CEOabuhb Caroline Saunders Senior Coroner (Gwent) Via email: gwent.coroner@newport.gov.uk Dear Ms Saunders Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Robyn Chambers which concluded on 11 July 2025. Thank you for your Regulation 28 Report dated and received by the Health Board on 24 July 2025. I am writing to provide you with the Health Board’s response, which was issued following the inquest into the death of Robyn Chambers. As requested, the information presented below is intended to describe the actions which have been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths. It is acknowledged that the Health Board was experiencing handover delays at all of its hospital sites on this day. During the previous days, all hospitals within the Health Board and indeed all hospitals across Wales experienced delays that were in excess of the 15 minutes standard as stipulated in the Welsh Health Circular (May 2016). The days leading up to the incident on 26 October 2024 saw very high attendances at the Grange University Hospital (GUH) with activity between 21 – 25 October being the highest during October, which placed significant additional pressure on services, particularly within the Emergency Department (ED). The management team have a number of processes in place to improve flow on a day- to-day basis. This is managed by the Corporate Site Clinical Operations Team who ensure that where delays are being experienced that the Health Board’s ‘Emergency Pressures Escalation Policy’ is actioned, this was the system in place in October 2024. This document provides clarity on the responsibilities of a wide range of Health Board colleagues including the Emergency Department, Operational Site Managers, Senior Divisional Leadership Teams and Executive Directors. This includes the actions that must be taken to reduce ambulance delays and manage wider system pressures. Please be assured that the eradication of handover delays over 15 minutes remains a top priority for the organisation. In terms of oversight and actions, the Health Board has refreshed its weekly oversight arrangements and changed the focus to whole system flow with the chair now being the Chief Operating Officer, with the Chief Executive chairing every fourth week. Input is also received from the Clinical Executives. These meetings include a clear focus on the delivery and performance of the Health Board’s Emergency Department and Minor Injury Units with very clear action plans to mitigate the risk and seek improvements in Ann Lloyd CBE, Cadeirydd | Chair 01633 435 957 Ann.Lloyd@wales.nhs.uk Nicola Prygodzicz, Prif Weithredwr | Chief Executive 01633 435 958 Nicola.Prygodzicz@wales.nhs.uk CEOabuhb patient flow and ambulance handover delays. Some of the most recent developments to support improvements in the Emergency Department at GUH specifically include the following: The business case for additional ED Consultants to reduce clinical assessment times was approved with the Health Board appointing a further 6 whole time equivalent ED Consultants. All will have commenced their new roles by September 2025. This will improve assessment and treatment capacity which will reduce waits and increase throughout of patients. A new larger transfer lounge opened in March 2025 which has capacity of 25 spaces (including chairs and beds) which will support flow throughout the day enabling earlier transfer of patients from the ED department to the relevant ward areas. The new ED extension is due for completion in the next few months which will offer additional assessment spaces for the clinical teams in addition to improved patient experience. In addition to the developments and improvements that directly focus on the emergency department there is the Six Goals programme of work that has a system wide focus to avoid unnecessary admissions, improve patient flow throughout the hospital system and reduce delays in discharges. Some of these are described below, all of which are expected to improve patient flow, reduce congestion at the ED department and improve ambulance handover delays. 1. Community Falls Response a. Implement a consistent 7-day community falls response service in partnership with WAST b. Increase utilization of the established falls system navigation pathway to identify the most appropriate location for initial assessment c. Develop a process to improve Front door responsiveness for non-injurious falls patients conveyed to hospital 2. Single Point of Access a. Delivery of a single point of access navigation hub for health professionals referring into the health board reducing hand-offs and increasing utilization of alternate pathways b. Partner with WAST to embed advanced Paramedic Practioner capacity within the navigation Hub to undertake assessment of waiting calls and interventions to prevent unnecessary attendances and admissions Ann Lloyd CBE, Cadeirydd | Chair 01633 435 957 Ann.Lloyd@wales.nhs.uk Nicola Prygodzicz, Prif Weithredwr | Chief Executive 01633 435 958 Nicola.Prygodzicz@wales.nhs.uk CEOabuhb c. Implement a clinical MDT review of appropriate patients referred into the single point of access with the aim of identifying appropriate alternative pathways 3. Frailty a. Care home programme encompassing the provision of equipment, training and future care plan development designed to reduce conveyances to hospital and deliver care closer to home b. Implement direct access to community beds for appropriate frail patients thus avoiding admission to an acute setting c. Aligning community and front door frailty teams to identify frail patients within the Emergency department and assessment units aiming to enable discharge home with appropriate support 4. Discharge a. Embed national ‘optimal hospital flow Framework’ across acute and community hospitals in Gwent including standardized board round processes b. Maximize capacity of the dedicated Transfer & Discharge Lounge at the Grange University Hospital c. Development of digital platform to enhance visibility to patient status at each stage of the pathway, enabling improved patient flow d. Focus on longest-staying patients via weekly scrutiny panels and improved system escalation e. Develop a criteria led discharge approach that uses agreed clinical criteria to ensure timely and safe discharge 5. Leadership and Culture a. Strengthened the senior clinical leadership at the Grange University Hospital to focus on patient flow and handover delays by the appointment of a dedicated Associate Director of Clinical Operations (Acute Services), ensuring that ambulance handover delays and subsequent patient flow blocks are escalated at an appropriately senior level. This includes real time liaison with the divisional triumvirates and directorates within the Clinical Divisions and liaison with colleagues across our five Local Authorities. b. Reviewed our Emergency Pressures Escalation Policy to ensure it aligns with the NHS Wales Guidance ‘A Framework for Urgent & Emergency Care System Ann Lloyd CBE, Cadeirydd | Chair 01633 435 957 Ann.Lloyd@wales.nhs.uk Nicola Prygodzicz, Prif Weithredwr | Chief Executive 01633 435 958 Nicola.Prygodzicz@wales.nhs.uk CEOabuhb Escalation’ document. This provides clarity on how, who and when to escalate delays, issues, and concerns. c. Implemented the ‘Safe to Start’ agenda, looking at whether clinical wards can provide a safe environment in which to commence each day. These meetings commence daily at 08:20 are co-chaired by the Senior Nursing and Operations teams and provide clarity on each ward’s position so that any issues identified are resolved in real time and collaboratively. d. A national Ministerial Action Group is currently working on a national workstream aiming for no delays over 45 minutes across Wales which we are hugely committed to. This “Handover 45” workstream mandates that there will be no over 45-minute delays from November 2025 in Wales. The Health Board has already commenced a focused initiative based on this approach early September with early indications of positive progress. WAST, in conjunction with the Health Boards operate an ‘Immediate Release Direction Protocol’ which outlines the principles and processes for the management of immediate release directions that includes a dynamic escalation process to, as far as possible, minimise patient safety risk for patients awaiting a response in our communities when ambulance capacity is reduced or when the time for patient handover at emergency departments is extended (the handover standard is 15 minutes and considered extended beyond 30 minutes). Review of the internal Immediate Release Protocol is being undertaken to ensure compliance with WAST’s revised ‘purple’ 999 response. During 26 October, whilst noting that the Health Board did have significant challenges with adhering to the nationally agreed 15-minute ambulance handover time, WAST did not contact the Health Board via approved routes to ask for a vehicle to be released. The 999 call to attend to Robyn Chambers had been upgraded and coded as an amber 1 response and fell within the provision of the Immediate Release Direction Protocol. Had this occurred, the Health Board would have endeavoured, as per the protocol to release a delayed vehicle to respond as requested. Finally, I would wish to reassure you that the Health Board is rigorously focused on the reduction of ambulance handovers and the associated risk for patients that these delays create. As a result of the ongoing work described above, we have already seen signs of improved performance across a number of key metrics including ambulance handover lost hours, delays over 1 hour, 12 waits in the emergency department and waits to be seen by a clinician. Embedding and sustaining the changes through the new Handover 45 project is now the key focus to see sustained improvements in this area. The whole Executive Team are providing leadership and challenge to addressing this important issue and it continues to be a top priority for the Health Board. Ann Lloyd CBE, Cadeirydd | Chair 01633 435 957 Ann.Lloyd@wales.nhs.uk Nicola Prygodzicz, Prif Weithredwr | Chief Executive 01633 435 958 Nicola.Prygodzicz@wales.nhs.uk CEOabuhb I trust that this information reassures you about the Health Board’s plans to improve ambulance handover delays. However, if you require any further information or assurance, please do not hesitate to contact me. Yours sincerely Nicola Prygodzicz Chief Executive
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