Pin
Get email alerts
Request correction
Investigation and inquest
On 18/09/2023, an investigation was opened touching upon the death of:
Sylvia Eileen Evans
The investigation concluded at the end of the inquest on 14/05/2024
The conclusion of the inquest was recorded as:
Death by Accident.
The medical cause of death was:
1a) Ischaemic heart disease
1b) Coronary Artery Disease
1c)
2 Blood loss from leg wound. Atrial Fibrillation (on anticoagulants)
Circumstances of the death
On 05/09/2023, Sylvia Eileen Evans sustained an accidental wound to her leg at home, which caused a severe haemorrhage. This in turn put pressure on her heart, the function of which was already compromised by extensive ischaemic heart disease. The effects were overwhelming and resulted in Sylvia’s death on 06/09/2023 at her home address.
Coroner’s concerns
Sylvia Evans suffered an injury to her leg which caused extensive blood loss. At 22:56 hours she called for an ambulance. The call ended abruptly, and the inquest determined that Sylvia was bleeding heavily and suffering the effects of heart failure exacerbated by severe haemorrhage, which caused her to end the call. The nature of her injuries had not been conveyed to the call handler.
The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
Information checked against the published report and official responses