Source · Prevention of Future Deaths

Raymond Gillespie

Ref: 2022-0154 Date: 25 May 2022 Coroner: Kate Sutherland Area: North Wales (East & Central) Responses identified: 0 / 1 View PDF

Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

Date 25 May 2022

56-day deadline 20 Jul 2022

Responses identified 0 of 1

Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

View full coroner's concerns

(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call

(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.

(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.

(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.

Report sections

Investigation and inquest

On 4.11.22, an investigation was commenced into the death of Raymond Gillespie. The investigation concluded at the end of an Inquest on 24 May 2022. The conclusion of the inquest was :- Natural causes contributed to by a fall The medical cause of death was 1a. frailty of old age, dementia, chronic kidney disease
2. Acute on chronic kidney disease, fractured neck of right femur (non-operated)

Circumstances of the death

These were recorded as :- Raymond Gillespie was a care home resident suffering from a number of comorbidities. On 8 October 2021 he suffered an unwitnessed fall. Welsh Ambulance Service Trust (WAST) were contacted at 21.59 due to hip pain and potential fracture. An initial response of 6 hours was provided for response (health care professional category, extended from 4 due to resource issues). Several welfare checks were conducted throughout the night by WAST. The following day at 11.40 a further 999 call was made by the care home as there was still no WAST attendance. At 12.57 a paramedic arrived, some 14 hours and 58 minutes following the initial call.

Copies sent to

and the Health Inspectorate Wales

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Report details

Reference: 2022-0154
Date of report: 25 May 2022
Coroner: Kate Sutherland
Coroner area: North Wales (East & Central)

Responses identified

Responses identified 0 of 1

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Jul 2022.

Sent to

Welsh Ambulance NHS Foundation Trust and Betsi Cadwaladr University Local Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.