A MAN from Llangollen who died at Ysbyty Glan Clwyd after waiting more than seven hours for an ambulance was “asked not to phone again” by ambulance services as his condition worsened, an inquest heard.

David Philip Roberts died aged 73 at the Bodelwyddan hospital on June 27, 2022, after losing his balance and suffering from dizziness in the days prior.

At a full inquest held in Ruthin yesterday (July 19), Kate Robertson, assistant senior coroner for North Wales East and Central, gave a conclusion of death arising from natural causes based on findings.

Mr Roberts’ medical cause of death was recorded as multi-organ failure due to cardiogenic shock and myocardial infarction (heart attack), with hypertension and diabetes also contributing.

In a statement, Mr Roberts’ niece, Mandy Lawrence-Jones, said he was “set in his ways” and “fiercely independent”, adding that he “loved jigsaws and a pint in the afternoon”.

Mr Roberts was born in Llangollen on May 28, 1949, and was one of seven siblings, including twin sister Hilary.

He attended Ysgol Dinas Bran and became a tool setter, and never married or had children.

The inquest heard that on June 21, Mr Roberts started to suffer from dizziness while walking through the town on his way for a routine blood test at Llangollen Health Centre.

He rang his sister Anne, who picked him up and drove him to the surgery, where he was unable to keep his balance – a wheelchair was provided to him at the entrance.

Liz Chambers, a consultant nurse at the centre, said he felt “much better” while in the clinic, did not experience any chest pain or a loss of consciousness, but felt dizzy while standing and was sweaty.

After having his blood test, he was sent home without seeing a GP or having any further assessment.

The next day, he said he had a “fuzzy” head, but wouldn’t allow anything to be done, and refused to make an appointment.

He visited Llangollen Health Centre again that day, but his pulse rate was not monitored.

On June 23, he still felt unwell, but went shopping with Anne, where she said he “leaned on the trolley” but still refused to make an appointment.

Between 1 and 1.30pm that day, his sister found him collapsed on the floor, which he said happened at around 11am, and complained of back pain.

The first call to Welsh Ambulance Service (WAS) was made at 1.31pm, where they were told the wait would be around one and a half hours.

The service categorised the call as Amber Two, which is ‘serious but not life-threatening’.

Anne said that his eyes soon rolled to the back of his head, and he was made comfortable on the floor with a duvet and pillow, but at 2pm said he was “scared” and in more pain.

She made a second call at 3.28pm, by which time his face and neck were purple – she was told that it would be a three to five hour wait, and was “asked not to phone again”.


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This call was coded as Amber One, considered life-threatening.

A third call was made just after 6pm, and Mr Roberts was now in and out of consciousness, with “shallow” breathing - the call was again coded as Amber One.

At 9pm, an ambulance crew from Llanrwst arrived, and “did not expect him to be as poorly as he was”, and soon made contact with a cardiac team as Ysbyty Glan Clwyd for him to be taken straight to theatre – his total wait for an ambulance was seven hours and thirty-one minutes.

He arrived at the hospital at 11.10pm, but had the third call been correctly logged as Red, an ambulance would have got to him two hours and nine minutes sooner, according to WAS service manager Gillian Pleming.

This “individual error” stemmed from the call taker not recognising his shallow breathing was of graver concern.

A temporary pacemaker wire was admitted, but he was found to have bradycardia, and a “significant” heart attack had resulted in low heart rate and blood pressure.

He was given blood pressure medication, was ventilated, his heart rate was stabilised, and an occlusion in his artery was successfully treated.

An impaired pumping function and multi-organ failure had also developed, and he was “extremely unwell” when first seen at the hospital, according to Dr Eduardas Subkovas, a consultant interventional cardiologist.

Despite this, he was given an “extremely slim” chance of recovery, Dr Subkovas said, and the delay in getting an ambulance prevented doctors from salvaging much heart muscle.

He required renal replacement therapy due to myocardial infarction, and in the early hours of June 27 deteriorated further, and no longer responded at 3am.

At 7am, medical treatment was stopped and he died at 7.50am.

Mr Subkovas added that had a pulse rate been taken on his initial visit to the GP surgery, he would have immediately been referred to the cardiac centre in Bodelwyddan.

Concluding, Ms Robertson said she intended to write to the health centre to express concern that an ECG and pulse rate check were not undertaken , and to establish what their typical practice was, adding she expected a response.

Addressing Mr Roberts’ family, she said: “I see how visibly difficult it has been for you.

“If it helps, the information that was given on those three calls formed what the ambulance service need to know.

“My condolences to you on your loss, but I hope that by learning and any change that happens you take some comfort that things may be different for others.”