Alyn Rees · Prevention of Future Deaths report

On 10 December 2019 I commenced an investigation into the death of Alyn Lewis Rees, DOB: 3/10/1990
The investigation concluded at the end of the inquest on 26/8/2020
The conclusion of the inquest was recorded as Natural Causes
The medical cause of death was Disseminated Lymphoma

On 3rd December 2019 Alyn Rees became acutely unwell and an ambulance was called at 12:19 hours. This was the first of 6 calls.

Mr Rees was experiencing breathing difficulties and he had been informed by his GP at a recent attendance that he may be suffering from a pulmonary embolism although that diagnosis had not been formally made.

Mr Rees was designated an Amber 1 status by WAST

During the final phone call Mr Rees deteriorated and went into cardiac arrest. His status was changed to a Red Call. Sadly when the paramedics arrived at 14:17, he could not be revived and his death was confirmed at 14:39.

At post mortem examination it was determined that Mr Rees died from widespread disseminated lymphoma.

During the inquest I referred to a report from WAST which described the assessment process. I am of the opinion that the assessment made and the status afforded to Mr Rees throughout was correct and no criticism was made of this.

However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.

The report did not indicate what the expected response time for an Amber 1 call should be.

I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.

I should emphasise that I do not consider that in this case Mr Rees’ life would have been saved if he had received medical attention earlier. He was (quite unbeknownst to him) suffering from a widespread lymphoma which presented acutely on the day he died.