Emlyn Victor Roberts · Prevention of Future Deaths report

On the 17th March 2022 an investigation was commenced into the death of Emlyn Victor Roberts (DOB 09/05/48) who died at his home on the 14th March 2022. The investigation concluded at the end of the inquest on 5th of July 2023. The conclusion of the inquest was that the death was due to natural causes, namely 1(a) Left Sided Intrathoracic Haemorrhage (b) Ruptured Dissecting Aneurysm of the Arch of the Aorta

The circumstances of the death are that at 20.01 on the 13th of March 2022, the deceased called an ambulance complaining of a sudden onset of pain and trouble breathing. He made a further call at 00.20 but due to an absence of available resources, an ambulance was unable to attend for a further seven hours at 07.27 on the morning of the following day, when he was found deceased at his home. In total there was a delay of almost eleven and a half hours from the initial call for help.

Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.

It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.

It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).

I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.