Robyn Chambers

I am Caroline Saunders, Senior Coroner for the Area of Gwent

On 18/11/2024 an investigation was opened touching upon the death of Robyn Anne Chambers The investigation concluded at the end of the inquest on 11/7/2025 The conclusion of the inquest was recorded as Natural Causes The medical cause of death was: 1a) Lower Respiratory Tract Infection 1b) Chronic Lung Disease 1c) Extreme Prematurity. Hypoxic Ischaemic Encephalopathy. Epilepsy and Global Developmental delay.

1. Previous Duodenal Perforation.

Robyn Anne Chambers sustained hypoxic ischaemic encephalopathy when she was born prematurely at 23 weeks gestation. This led to significant physical and neurological problems, including ongoing respiratory problems. On 26/10/2024, Robyn developed a chest infection. Despite intensive treatment, the effects were overwhelming and resulted in Robyn’s death on 2/11/2024 at Ty Hafan Hospice in Sully.

The MATTERS OF CONCERN are as follows: – Following Robyn’s traumatic birth she was cared for at home by her parents. Robyn needed extensive medical intervention and monitoring at home. When she became unwell on 26/10/2024 her parents called an ambulance and were informed that it would take about 8 hours for an Amber 1 ambulance to respond. Robyn’s parents decided to take Robyn to hospital themselves which was a difficult and potentially dangerous journey because Robyn had complicated medical equipment that needed to remain attached. The estimated length of time for an ambulance to be dispatched and the decision taken by Robyn’s parents to convey her to hospital had no impact on Robyn’s care and did not affect the outcome. However, having heard evidence from Welsh Ambulance Service NHS Trust, I note that the main reason for the delay in dispatching emergency ambulances  remains  the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital. Evidence provided at inquest indicated that, at the time that Robyn’s parents called for an ambulance, the longest time an ambulance was delayed at the GUH was in excess of 10 hours.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I am concerned that despite previous assurances that action was being taken by ABUHB and WAST in relation to managing ambulance delays (which I appreciate can be multi-factorial) a significant problem remains in relation to the release of ambulances from the GUH Emergency Department. The handover times are far exceeding the 15-minute handover time agreed between these 2 organisations. Patients’ lives are being, and will continue to be, put at risk if this situation is not resolved.