CORONER I am John Adrian Gittins, Senior Coroner, for the coroner area of North Wales (East and Central)
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DATE OF REPORT 28th July 2026
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CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
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THIS REPORT IS BEING SENT TO The Chief Executive of the Welsh Ambulance Services University NHSTrust
Ty Elwy, Unit 7 Ffordd [REDACTED], St Asaph Business Park, St Asaph, Denbighshire LL15 2NG
You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd September 2026. I, the coroner, may extend the period if an appropriate application is made.
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YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided.
I will pass any representations received to the Chief Coroner for a decision.
Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online.
The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.
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SUMMARY OF CORONER’S CONCERN 1. Emergency services and urgent care a. Ambulance services 2. Delays a. Ambulance delays 3. Resources a. Availability of ambulances
The length of waiting time for an ambulance response due to the unavailability of resources.
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ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
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INVESTIGATION AND INQUEST On the 13th of January 2026, I commenced an investigation into the death of Dorothy Esther Evans (DOB 22.10.379.1.26). The investigation concluded at the end of the inquest on the 27th of July 2026. The cause of death was recorded as being due to 1(a) Multiorgan Failure (b) Pulmonary Emboli (c) Fractured neck of femur (operated) 2. Frailty of Old age and dementia and the conclusion of the inquest was that of an accidental death
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CIRCUMSTANCES OF DEATH The deceased fell at her residential home on the 31st of December 2025 sustaining an injury, and despite being found by carers, she remained on the floor until the following morning, despite no ambulance being called. When an emergency response was requested at 09.12 hours on the morning of the 3rd of January 2026, no ambulance response was possible until 09.17 hours on the 4th of January, 2026 , more than twenty fours after the original call. Despite medical treatment, the injury and long lies which she had endured led to her death at Glan Clwyd Hospital on the 9th of January 2026.
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CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows: The evidence provided to me at the inquest, both written and orally detailed multifactorial reasons for so-called ambulance delays, and it was acknowledged by the representative of WAST that lives are at risk as a result. Representations were also made whereby it was suggested to me that in essence there was nothing more which WAST could do to alleviate these issues and that only other agencies or organisations could affect change. However no evidence was made available as to which agencies were being referenced and the steps taken at the most senior levels to influence change, reduce delays and hence save lives..
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COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it.
I also may send a copy of the report to any other person who I believe may find it useful or of interest.
I can confirm I have sent the report to the family of the deceased.
I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses.
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Dated 28th July 2026 Signature [REDACTED] Senior Coroner for North Wales (East and Central)
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CORONER 
