Jeanette Sidlow Beech

I am Kate Robertson, Assistant Coroner for North Wales (East and Central)

On 6 August 2024 an investigation was commenced into the death of Jeanette  Sidlow Beech (DOB 8/7/1981) who died on 3 August 2024. The investigation  concluded at the end of the inquest on 28 May 2025. The conclusion of the inquest was a narrative conclusion:- Jeanette Sidlow Beech died on 3 August 2024 at her home address from an alcohol withdrawal related seizure likely related to previous prolonged excessive alcohol  use following a wait of 15 hours and 13 minutes for an ambulance

The circumstances of the death are as follows :- Jeanette Sidlow Beech had a history of alcohol withdrawal related seizures. On 2 August 2024, whilst at her home address, she began to feel unwell. Her husband contacted the Welsh Ambulance Service Trust (WAST) at 12.52 hours. The call was categorised as Green 3 response with an estimated time of arrival given as 2 hours. A second call was made at 15:16 hours indicating increased pain and vomiting with an impending seizure and had been upgraded to an Amber 2 category after clinical review. A third call was made at 03:51 hours when Jeanette was struggling to breathe, her body was seizing up and she was vomiting. The call was generated as red. A resource arrived at 04:05 hours. CPR was continued. Jeanette was confirmed as having passed away at 04:50 hours.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful. b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding  ambulance delays, there remains significant concerns with Hospital  handover delays. c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST. d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various  reasons. e. It appears to remain the case that the lack of social care provision and/or  Community Hospitals means that those fit to be discharged from district  general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be  provided with a bed in the hospitals such that ambulances remain outside  Emergency Departments for hours. Evidence was heard that between 2nd  and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the  longest delays in ambulance handover times were in excess of 6 hours and 7 hours. f. The issues identified are pertinent to WAST, the Health Board and Local Authorities. g. There appears to be no improvement in these ongoing issues and I am  particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation  persists.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.