Pin
Get email alerts
Request correction
Investigation and inquest
On 25/9/2023, an investigation was opened touching upon the death of Marjorie Joyce Michael
The investigation concluded at the end of the inquest on 17/7/2024
The conclusion of the inquest was recorded as
Narrative Conclusion:
“Marjorie Joyce Michael fell at ████████ residential home in Pontypool on 3/9/2023. Marjorie lay on the floor for over 14 hours waiting for an ambulance. She was eventually conveyed to hospital on 4/9/2023. The long lie resulted in the development of pneumonia and Marjorie died at Nevill Hall Hospital on 6/9/2023. Her death was contributed to by delayed ambulance response”.
The medical cause of death was:
1a) Hypostatic Pneumonia
1b) Fall, Long Lie
1c)
2 Type 2 Diabetes. Ischaemic Heart Disease.
Circumstances of the death
These are described in the Narrative Conclusion in Box 3.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
Marjorie Joyce Michael (MJM) fell at her residential Home on 4/9/2023. Carers were correctly advised by the ambulance call handler not to move her on the basis that this could worsen any injury she had sustained. As a result, MJM lay on the floor for over 14 hours waiting for an ambulance
As per the medical cause of death provided by ████████ Senior Clinical Fellow at Nevill Hall Hospital in Abergavenny, MJM’s death was directly attributable to the delayed ambulance response.
Despite ongoing attempts by Welsh Ambulance Service and Aneurin Bevan University Health Board, the delays in responding to emergency calls are not improving. Witness evidence confirmed the many initiatives undertaken by these services to improve ambulance response times but these continue to be undermined by the delay in releasing emergency ambulances from acute hospitals to attend emergency calls.
Witness evidence also confirmed that despite these initiatives there was no appreciable reduction in the length waiting times for Amber 1 and Amber 2 responses; which are categorised as potentially life-threatening emergencies.
