In a Prevention of Future Deaths Report, sent to Swansea Bay University Health Board and the Welsh Ambulance Service NHS Trust (WAST), acting senior coroner, Aled Gruffyd, said the ‘significant delay' resulted in the death of Peter Parker.

Parker dialled 999 for an ambulanced at 9.19pm on 10 September 2021 after having cut himself on broken glass at his home. The line disconnected while the WAST call handler gave advice to Parker on how to stop the bleeding. The call handler was unable to reconnect the call after five attempts.

The call was given an Amber 1 priority under the MPDS system which was intended to mean a response within 20 minutes, however, due to a delay caused by ambulances waiting to offload patients to hospitals, the crew did not arrive on the scene until 7am the following day. Parker was pronounced dead at 7.09am. The coroner noted the time of survival of such injuries was 30-45 minutes.

A Swansea Bay University Health Board spokesperson said: ‘We extend our sincere condolences to the family and friends of Mr Parker for their loss. The health board is in the process of reviewing the findings of the Prevention of Future Deaths report and will be responding to the coroner.'

Lee Brooks, executive director of operations at WAST, issued the trust's condolence to Parker's family and loved ones, adding: ‘Currently, ambulance crews spend a large proportion of their time supporting patients outside Emergency Departments, which of course means that they are not able to attend other calls in the community.

"We're actively looking at what we can do to use the skills of our people differently, to manage patients closer to home and make our emergency ambulances more readily available for patients like Mr Parker.'