Source · Prevention of Future Deaths
Catherine Roberts
Ref: 2017-0076
Date: 7 Jul 2017
Coroner: Nicola Jones
Area: North Wales (East and Central)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner notes persistent issues with Emergency Department admission, resource availability, and patient flow continue to place lives at risk. An effective system plan to address these long-standing problems has not yet been agreed despite previous reports.
Date
7 Jul 2017
56-day deadline
1 Sep 2017
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner notes persistent issues with Emergency Department admission, resource availability, and patient flow continue to place lives at risk. An effective system plan to address these long-standing problems has not yet been agreed despite previous reports.
View full coroner's concerns
The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present day and patients' lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place.
Despite the above reports issued to the Health Board these problems continue to the present day and patients' lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place.
Report sections
Investigation and inquest
On the 15th of February 2016 I commenced an investigation into the death of Catherine Haf Roberts (DOB 26 May 1933 DOD 11 February 2016) The investigation concluded at the end of the inquest on the 5th of February 2017. The conclusion of the inquest was one of Natural Causes, the Cause of Death being recorded as 1(a) Acute Gastroenteritis
Circumstances of the death
Mrs Roberts arrived at Ysbyty Glan Clwyd by ambulance at 01.26 hours on 6 February 2016 after becoming unwell at home with persistent diarrhoea. She waited in an ambulance outside hospital until 03.25 hours due to the emergency department being full to capacity and Mrs Roberts requiring a cubicle. As there was no space within the hospital on a medical ward Mrs Roberts remained in the emergency department for 58 hours before being transferred to a medical ward where her condition deteriorated. Mrs Roberts died in hospital on 11 February 2016.
Action should be taken
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 IYN Tel 01824 708047 | Fax 01824 708048
Copies sent to
of the Deceased
Similar PFD reports
Report details
- Reference
- 2017-0076
- Date of report
- 7 July 2017
- Coroner
- Nicola Jones
- Coroner area
- North Wales (East and 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: 1 Sep 2017 (stated in the report).
Sent to
- Betsi Cadwaladr University Health Board