Ambulance delays have become “beyond intolerable”, causing patients to die “directly and indirectly as a consequence”, a senior coroner has told Wales’ First Minister
Ambulance delays have become “beyond intolerable”, causing patients to die “directly and indirectly as a consequence”, a senior coroner has told Wales’ First Minister
Ambulance delays have become “beyond intolerable”, causing patients to die “directly and indirectly as a consequence”, a senior coroner has told Wales’ First Minister
Graeme Hughes made the comments in a report to the First Minister Eluned Morgan, following an inquest into the death of an 89-year-old woman who waited 14 hours after a fall.
He said more could die unless something is done to reduce the time it takes to handover patients from paramedics to hospitals.
The Welsh Conservative Senedd leader, Darren Millar, said it was "unprecedented" for a coroner to write directly to the first minister. Morgan said the advice of coroners was taken "very seriously".
She said the problem lay in delays transferring people from hospital into social care.
The senior coroner for South Wales Central raised his concerns in a "prevention of future deaths" report - one of a large number that have been sent to health boards and the Welsh government by coroners in recent years.
At least seven since May 2024 have been issued which raise concerns over ambulance response times, including several to Morgan when she was health minister.
Other reports in 2025 included the case of a man who died from bleeding from his wrist after a fall on glass, and a woman who died of sepsis. Both those incidents involved very long waits for a paramedic.
The coroner told the first minister that the "prevalence and extent of such delays has become beyond intolerable and is leading to many acutely unwell patients in the community waiting for such prolonged periods for emergency care, dying directly and indirectly as a consequence".
His comments followed his investigation into the death of Valerie Hill, who died at the Royal Glamorgan Hospital in March 2022 days after a fall at her care home in Treharris, near Merthyr Tydfil.
Listing pneumonia and a fall leading to a fracture as causes of her death, the inquest learned that Mrs Hill had been lying on a floor for over 14 hours while waiting for an ambulance to attend.
But the coroner added that long ambulance handover times across Cwm Taf Morgannwg health board had possibly contributed to the 14 hour wait, which exacerbated known medical conditions.
He told the first minister "in the three years since Valerie's death you have received multiple prevention of future death reports from myself and fellow coroner's in Wales highlighting the devastating outcomes attributable to delays in conveying acutely unwell patients to hospital/ambulance handover delays".
"Those risks continue," he said.
He quoted the first minister's response to an earlier report, saying she had set a "priority" for an improvement of "patient flow".
The coroner said this had not led "to any discernible improvement".
He said the health board itself had told the inquest its performance was "not the worst in Wales".
There has been a deterioration in amber response times - serious but not immediately life-threatening calls – from a median wait of around 50 minutes on average in winter 2019 to more than 150 minutes last winter.
The number of "lost hours" due to handover delays at hospitals has also increased from around 6000-8000 for some months in 2018 to 30,000 hours at peak months last year.
The figure for March 2022 at the time of Mrs Hill's fall was over 24,000 hours.
In Cardiff Bay on Tuesday, Welsh Conservative Senedd leader Darren Millar said of the 25 prevention of future death reports issued since last August, five were directly linked to ambulance delays.
Morgan said the reports were taken "extremely seriously", and that there had been a "huge amount of work done to try and move forward with a programme of how we can speed up that response".
"We know that part of the problem is delayed transfers of care," she said. "If you want to fix the NHS, you have to make sure that you fix care."
She went on: "So, stop moaning, because that's the way that you actually fix things."
In response to the inquest into Valerie Hill's death, a spokesperson for Cwm Taf Morgannwg University Health Board said: "We extend our sincere condolences to the family of Valerie Hill during this extremely difficult time."
The spokesperson added: "We are fully committed to learning from this case, which will help inform improvements in our services for the future."
The Welsh government said: "We have been clear with health boards about our expectations in terms of responding to these reports and about improving ambulance handovers.
"We have established a national, clinically-led taskforce to support these efforts."
Jane Dodds, leader of the Welsh Liberal Democrats, said: "These tragic deaths lay bare a broken system, where ambulance delays are the direct result of gridlocked hospitals and an overstretched, under-prioritised social care sector."
The Welsh Ambulance Service's Liam Williams said ambulance delays "are a symptom of a much broader, system-wide issue and we're grateful to coroners for their thorough exploration of the issues".
