TWO health chiefs took the witness stand to explain what steps are being taken to address the ongoing problem of ambulance delays and admission to hospital.

Jason Killens and Carol Shillabeer, chief executives of the Welsh Ambulance Services Trust and the Betsi Cadwaladr University Health Board respectively, were called as witnesses at an inquest into the death of a Holywell pensioner who had to wait 23 hours for an ambulance.

Gwyneth Jones, 84, died at Glan Clwyd Hospital on November 28, 2021, the cause of death being bronchial pneumonia due to a bleed on the brain.

Evidence was given at the Ruthin hearing that the former office worker and her husband Eric were residents at the Llys Gwenffrwd Home. 

She had fallen previously and on October 25 was found on the floor alongside her bed at 8.30am.

Staff called an ambulance and after five hours were advised to put her in bed. 

There were repeated 999 calls and call handlers made welfare checks but an ambulance did not arrive until 7.30am the following morning.

Mrs Jones, a former office worker, was taken to Glan Clwyd Hospital where no fractures were found, and was then returned to Llys Gwenffrwd.

There she became “vacant” and unable to speak, so was taken back to hospital, but had to wait in the ambulance for five hours.

She was found to have a bleed on the brain after a head injury, and her condition deteriorated.

In a statement read at the inquest Gill Pleming, WAST’s operations manager, said the calls had been correctly categorised but there was simply no ambulance available.

Mrs Jones’s daughter Annette Jones said in a statement she had no concerns about the care and treatment her mother received in the home or hospital, but added: “We query whether, in the long wait on both days, something was missed.”

Having issued several Prevention of Future Death notices in the past voicing concern about such delays, John Gittins, senior coroner for North Wales East and Central, called the two Chief Executives to update him on the current situation, what progress was being made in tackling the “multifactorial” problem and its effect on staff.

Both officers outlined the practical steps in reducing the number of patients requiring an ambulance and emergency treatment, co-operating with local authorities in increasing social care to enable patients to be discharged from hospital and increasing efficiency.

Asked by the Coroner about the effect on crews of having to queue outside hospital emergency departments, Mr Killens replied: “It is not uncommon for crews to spend their entire 12-hour shifts waiting and it leads to frustration and higher absence rates.”

Hearing of other calls they could be responding to caused stress and anxiety, he added.


Ms Shillabeer said she had met officers of every local authority in the region to discuss the issue of social provision for patients who no longer need to be in hospital.

Recording a conclusion of accidental death, Mr Gittins said there would be no realistic benefit in issuing a Prevention of Future Deaths report because it came down to a matter of the resources which were available.

But he added: “I am going to continue to hold people to account.”

After the inquest Mr Killens said: “Ambulance delays are a symptom of a much broader, system-wide issue and we’re grateful to the coroner for his thorough exploration of the issues, and more importantly, the opportunity to talk about what we are doing differently.

“In the meantime, we have worked with Betsi Cadwaladr University Health Board to identify a number of areas for greater collaboration and support, with clear agreement on the need to improve issues related to emergency ambulance availability in north Wales.

“This dialogue will continue to ensure that health board and WAST plans are aligned, and that collaborative effort leads to improved experience and outcome for patients.”

Ms Shillabeer said: “This inquest has really helped to highlight the issues in emergency care and how it’s a symptom of bottlenecks in the wider health and social care system.

“We are working closely with all partners, including the Welsh Ambulance Service University NHS Trust and other public sector partners, to work smarter and accelerate discharges for those who are medically fit to leave our hospitals.

“This will help reduce pressures on Emergency Departments and ambulance services.

"I met recently with Jason Killens, the Trust’s CEO, to discuss how we move forward together and will continue to do so.”