Ambulance crew availability reduced by hospital handover delays
NHS England received 16 coroners' reports about this hazard between 18 May 2016 and 3 Apr 2026.
They came from 13 different coroners in 12 coroner areas. A similar concern was raised again 15 times after the first warning.
A published response was found for 15 of the 15 earlier reports, stating 18 specific actions.
The story, report by report
Spacing grows with the time between reports.
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the High quality care for all, now and for future generations outcome of previous similar 999 calls as well as the concerns raised by Coroners in Regulation 28 Reports. We anticipate making recommendations in autumn 2016. It is our intention that this review should improve the service provided and clinical outcomes for future patients contacting the 9”
Stated timescale: autumn 2016
Web search (Tavily): No evidence found either way
Ambulance Response Programme Clinical Coding Tria ↗- 0 months later
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
Web search (Tavily): Evidence found that the action was carried out
East of England Ambulance: Plan to recruit 350 staff ↗“The need for an urgent review of resources to reduce the risk of future deaths”
Stated timescale: 2016/17 contract
Web search (Tavily): No evidence found either way
Capacity pressures in health and social care in England ↗ - 7 years 2 months later
“delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 0 months later
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
Original on judiciary.uk ↗ NHS England responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗
“In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”
Web search (Tavily): No evidence found either way
Quality Standard for Imaging - College of Radiographers ↗“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
Stated timescale: 2024/25
Web search (Tavily): No evidence found either way
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS ↗2 more stated actions in the Promises tab.
- 5 months later
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Escambia County EMS ambulance response times to improve ↗ - 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulanceresource
NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS ↗“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
- 0 months laterIdentical hazardConfidence 0.92 · higha different coroner
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulancehoursminutescall
NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.”
Web search (Tavily): No evidence found either way
Reducing ambulance handover delays: key lines of enquiry ↗“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlined key actions to”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Ambulance service response times ↗ - 0 months laterClosely relatedConfidence 0.90 · higha different coroner
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Ambulance Response Programme (ARP) Impact Assessment ↗ - 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr [name redacted] death, still remain outside of the target response standards (both on average and at the 90th centile).”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Original on judiciary.uk ↗ Repeated from the earlier report:targetCategorywaitambulancehours
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 1 month later
Raised again · 10th time
Colin Wiles↗
24 Nov 2024 · Sally Robinson · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Closely relatedConfidence 0.90 · higha different coroner“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times: Phase 1: Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire Ambulance Service (YAS) staff were instructed to leave.”
Stated timescale: 9th December 2023
Web search (Tavily): No evidence found either way
Construction Handover: Top Methods for Efficient Project Handover | Kahua ↗“Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers are essential to ensure patients reach definitive care promptly, which includes both those waiting to receive care in the emergency department (ED), and those waiting in the community. NHS England are continuing to work with trusts and services with significant handover challenges at the 'front end', alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient”
Stated timescale: 2024/25
Web search (Tavily): No evidence found either way
Reducing ambulance handover delays | Health Spaces 🏥 ↗ - 1 month laterIdentical hazardConfidence 0.94 · higha different coroner
“I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.”
Original on judiciary.uk ↗ Repeated from the earlier report:hourshospitals
NHS England responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published.”
- 1 month laterIdentical hazardConfidence 0.95 · higha different coroner
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services.”
Stated timescale: 2025/26
Web search (Tavily): No evidence found either way
Ambulance service response times ↗“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
Stated timescale: 2025-26
Web search (Tavily): No evidence found either way
The latest update on the W45 / Rapid Release Protocols ↗ - 1 month later
Raised again · 13th time
Diana Fairweather-Purkis↗
17 Feb 2025 · Paul Appleton · Teesside and Hartlepool
Identical hazardConfidence 0.95 · higha different coroner“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗ Repeated from the earlier report:AmbulanceService
NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 1 year laterIdentical hazardConfidence 0.92 · higha different coroner
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulancetimestime
NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 1 month laterIdentical hazardConfidence 0.95 · higha different coroner
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulancetimeshospitalsresponse
The most recent report. A response may not be due or published yet.
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2016 → 2024Jade Griffiths-Jones7 years 11 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance resources leading to delayed responses and risk to patients. The earlier report cites general resource shortages and capacity management plans, while the later report specifies that hospital handover delays caused the resource shortage.
Peter Scott · 26 May 2016
“I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report”
Original on judiciary.uk ↗ Jade Griffiths-Jones · 17 Apr 2024
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The need for an urgent review of resources to reduce the risk of future deaths”
2023 → 2024Jade Griffiths-Jones9 months after Lee Dryden · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that ambulance services could not meet category 2 response targets because hospital handover delays left insufficient ambulances available.
Lee Dryden · 2 Aug 2023
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
Original on judiciary.uk ↗ Jade Griffiths-Jones · 17 Apr 2024
“first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised.”
Original on judiciary.uk ↗ 2023 → 2024Sophie Hindmarsh9 months after Lee Dryden · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports describe prolonged ambulance response times caused by delays in hospital patient off‑loading/handover that left ambulances unavailable.
Lee Dryden · 2 Aug 2023
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
Original on judiciary.uk ↗ Sophie Hindmarsh · 29 Apr 2024
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Original on judiciary.uk ↗ 2016 → 2024Sophie Hindmarsh7 years 11 months after Christopher Fields · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that ambulance services took far longer than the target response time to reach patients. The core issue is excessive delays in ambulance arrival despite appropriate call categorisation.
Christopher Fields · 18 May 2016
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Original on judiciary.uk ↗ Sophie Hindmarsh · 29 Apr 2024
“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”
2016 → 2024Michael Clarke7 years 11 months after Christopher Fields · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessively long ambulance response times caused by high demand and resource constraints. The earlier case involved a 2‑hour‑8‑minute delay for a Green 2 call; the later case notes category 3 waits exceeding 4 hours against a 1‑hour target.
Christopher Fields · 18 May 2016
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Original on judiciary.uk ↗ Michael Clarke · 3 May 2024
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”
2023 → 2024Josh Smith11 months after Lee Dryden · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that delays in hospital handover of patients cause ambulances to remain unavailable, leading to prolonged response times for emergency calls.
Lee Dryden · 2 Aug 2023
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
Original on judiciary.uk ↗ Josh Smith · 15 Jul 2024
“Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr [name redacted] death, still remain outside of the target response standards (both on average and at the 90th centile).”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
2024 → 2024Simon Boyd6 months after Michael Clarke · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that ambulance response times for category 3 calls consistently exceed national targets, causing dangerous delays.
Michael Clarke · 3 May 2024
“The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Original on judiciary.uk ↗ Simon Boyd · 6 Nov 2024
“The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Original on judiciary.uk ↗ 2023 → 2024Simon Boyd1 year 3 months after Lee Dryden · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that ambulance services are failing to meet national response‑time targets, leading to dangerously long waits for patients.
Lee Dryden · 2 Aug 2023
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
Original on judiciary.uk ↗ Simon Boyd · 6 Nov 2024
“notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
2016 → 2024Colin Wiles8 years 6 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessive delays in handing over patients from ambulances to hospital emergency departments as a safety concern. The earlier report calls for general strategies to improve handover times, while the later report cites a specific incident at Hull Royal Infirmary causing significant lost ambulance time.
Peter Scott · 26 May 2016
“Consideration should be given to strategies to improve handover times at hospitals.”
Original on judiciary.uk ↗ Colin Wiles · 24 Nov 2024
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Original on judiciary.uk ↗ 2024 → 2024Andrew Lewis8 months after Sophie Hindmarsh · different coronerIdentical hazardConfidence 0.94 · high
Identical hazardConfidence 0.94 · highBoth reports highlight excessive ambulance response delays caused by prolonged hospital handover or queuing times that tie up ambulance resources.
Sophie Hindmarsh · 29 Apr 2024
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
Original on judiciary.uk ↗ Andrew Lewis · 19 Dec 2024
“I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.”
Original on judiciary.uk ↗ 2023 → 2024Andrew Lewis1 year 5 months after Lee Dryden · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that ambulance response delays are caused by the service operating at high escalation levels combined with significant hospital handover queues, which reduce ambulance availability.
Lee Dryden · 2 Aug 2023
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
Original on judiciary.uk ↗ Andrew Lewis · 19 Dec 2024
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Original on judiciary.uk ↗ 2024 → 2024Andrew Lewis8 months after Michael Clarke · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessively long ambulance response times caused by high demand and system pressure. The earlier report focuses on category 3 calls exceeding the 1‑hour target, while the later report describes a case where help arrived many hours after a 2‑hour target was set.
Michael Clarke · 3 May 2024
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour”
Original on judiciary.uk ↗ Andrew Lewis · 19 Dec 2024
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Original on judiciary.uk ↗ 2024 → 2025Nicola Owens9 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports describe ambulance crew availability being reduced by delays in hospital handovers, which leads to longer response times and risk to patients. The later report adds that social‑care backlogs exacerbate the handover delays, but the core hazard remains the same.
Jade Griffiths-Jones · 17 Apr 2024
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”
Original on judiciary.uk ↗ Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
2016 → 2025Nicola Owens8 years 8 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify delayed patient handover at hospitals as a factor that reduces ambulance availability and risks patient safety. The later report adds that handover delays are worsened by social‑care discharge backlogs, while the earlier report focuses on the need to improve handover times.
Peter Scott · 26 May 2016
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
Original on judiciary.uk ↗ Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Original on judiciary.uk ↗ 2024 → 2025Nicola Owens9 months after Sophie Hindmarsh · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify hospital handover/offload delays as the cause of ambulance unavailability, which impedes emergency response. The later report adds that these delays stem from a backlog of patients awaiting social care, but the core hazard remains the same.
Sophie Hindmarsh · 29 Apr 2024
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
Original on judiciary.uk ↗ Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Original on judiciary.uk ↗ 2024 → 2025Nicola Owens1 year 1 month after Dennis King · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight delays in patient care caused by insufficient ambulance availability. The later report adds that handover delays and social‑care backlogs exacerbate the same core problem.
Dennis King · 15 Jan 2024
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Original on judiciary.uk ↗ Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Original on judiciary.uk ↗ 2023 → 2025Nicola Owens1 year 6 months after Albert Dovey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify delays in ambulance response and patient assessment caused by hospital handover bottlenecks.
Albert Dovey · 20 Jul 2023
“delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital.”
Original on judiciary.uk ↗ Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Original on judiciary.uk ↗ 2016 → 2025Diana Fairweather-Purkis8 years 9 months after Peter Scott · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight insufficient ambulance resources leading to delayed response and patient handovers.
Peter Scott · 26 May 2016
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The need for an urgent review of resources to reduce the risk of future deaths”
2024 → 2025Diana Fairweather-Purkis10 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe ambulance crew availability being reduced because patients experience long handover delays at hospitals, leading to slower response times.
Jade Griffiths-Jones · 17 Apr 2024
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
2024 → 2025Diana Fairweather-Purkis1 year 1 month after Dennis King · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance availability/resources leading to delayed patient attendance and transfers. The later report adds handover delays but shares the core concern of inadequate ambulance capacity.
Dennis King · 15 Jan 2024
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗ 2023 → 2025Diana Fairweather-Purkis1 year 7 months after Albert Dovey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight delays in ambulance handover at hospitals that impede timely patient assessment and care. The earlier report focuses on assessment delays due to ambulance attendance and processing delays, while the later report emphasizes crew release delays caused by hand‑over bottlenecks.
Albert Dovey · 20 Jul 2023
“delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital.”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
Original on judiciary.uk ↗ 2024 → 2025Diana Fairweather-Purkis7 months after Josh Smith · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify delays in ambulance patient handover at hospitals as the core problem affecting ambulance availability and response times. The later report focuses on the consequence of these handover delays—excessive delays in releasing ambulance crews—while the earlier report notes the impact on overall ambulance response speed.
Josh Smith · 15 Jul 2024
“delays in this process continue to impact upon the speed of the ambulance response to patients waiting within the community.”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
Original on judiciary.uk ↗ 2024 → 2026Roman Barr1 year 3 months after Colin Wiles · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports identify prolonged ambulance handover times at hospitals as a problem that reduces ambulance availability and increases risk.
Colin Wiles · 24 Nov 2024
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Original on judiciary.uk ↗ Roman Barr · 4 Mar 2026
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ 2016 → 2026Roman Barr9 years 9 months after Peter Scott · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify prolonged ambulance handover times at hospitals as a safety issue that reduces ambulance availability.
Peter Scott · 26 May 2016
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
Original on judiciary.uk ↗ Roman Barr · 4 Mar 2026
“3. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ 2024 → 2026Roman Barr1 year 11 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify hospital handover delays as a factor that reduces ambulance availability and worsens response times. The later report reiterates that prolonged handover times lead to no ambulance being available when help is sought.
Jade Griffiths-Jones · 17 Apr 2024
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
Original on judiciary.uk ↗ Roman Barr · 4 Mar 2026
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
2024 → 2026Roman Barr2 years after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports identify ambulance handover delays at hospitals as reducing ambulance availability and increasing risk to life.
Jade Griffiths-Jones · 17 Apr 2024
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
2016 → 2026Roman Barr9 years 10 months after Peter Scott · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability and increases risk to the public.
Peter Scott · 26 May 2016
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ 2025 → 2026Roman Barr1 year 2 months after Nicola Owens · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability for emergency calls.
Nicola Owens · 31 Jan 2025
“This delay being significantly contributed to by the handover delays in hospitals.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
2024 → 2026Roman Barr1 year 4 months after Colin Wiles · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight prolonged ambulance handover times at hospitals as a problem that reduces ambulance availability. The later report adds context about emergency response capacity but the core hazard is the same.
Colin Wiles · 24 Nov 2024
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Original on judiciary.uk ↗ 2024 → 2026Roman Barr2 years 3 months after Dennis King · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with ambulance availability that impede timely emergency care. The earlier report focuses on delays in transferring patients between hospitals, while the later report points to handover delays at hospitals reducing ambulance availability.
Dennis King · 15 Jan 2024
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Original on judiciary.uk ↗
Stated action · timescale: autumn 2016
“NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the High quality care for all, now and for future generations outcome of previous similar 999 calls as well as the concerns raised by Coroners in Regulation 28 Reports. We anticipate making recommendations in autumn 2016. It is our intention that this review should improve the service provided and clinical outcomes for future patients contacting the 9”
What happened next: No evidence found either way
NHS England's 2016 plan to review ambulance coding systems and trial a new system was not confirmed to have been completed by autumn 2016 in the provided sources.
“The ARP Expert Reference Group (ERG) and the Clinical Coding Trial Operational Group (CCTOG) have developed a modified set of Ambulance Quality Indicators (AQIs) for the trial alongside a set of critical review criteria. As with our two current trial sites senior operational staff from WMAS, who have been involved in the process throughout, will be in the ambulance control room at go live,”
No evidence found does not mean the action did not happen.
Stated action
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
What happened next: Evidence found that the action was carried out
The trust announced plans to recruit over 350 staff to improve patient care and staff morale, citing £5m of additional investment for new posts.
“The trust's "turnaround plan" lists measures including recruiting more paramedics, tackling sickness and restructuring management.”
“The trust said it planned to recruit 82 specialist paramedics, 149 paramedics, 24 emergency medical technicians and 96 emergency care assistants.”
“The recruitment drive, in addition to reducing staff sickness and its spending on private ambulances, would enable it to provide the equivalent of an extra 25 of its own double-staffed ambulances, available around the clock,”
Stated action · timescale: 2016/17 contract
“The need for an urgent review of resources to reduce the risk of future deaths”
What happened next: No evidence found either way
The document does not mention any review of resources or a 2016/17 contract timescale.
“Capacity pressures in health and social care in England”
“Ambulance Response Programme Review NHS England Gateway Publication Reference: 08296 Ambulance Response Programme Review <Blank Page> Equality and Health Inequalities Statement Promoting equality and addressing health inequalities are at the heart of NHS England's values. Throughout the development of the policies and processes cited in this document, we have: - Given due regard to the need to”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action
“In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”
What happened next: No evidence found either way
No source confirms that the North East & Yorkshire systems were asked for assurance about national guidance compliance.
“The quality standard for imaging (QSI) is designed to be used within a service as a measure of quality against which quality improvement, patient experience and involvement can be achieved. It articulates the expectations of good imaging services. Services that demonstrate their achievement of the QSI are eligible to apply for the award of the QSI Quality [name redacted].”
“The regional medical imaging interoperability network which serves 4-Million patients throughout Yorkshire, the Humber and North Lincolnshire”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2024/25
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
What happened next: No evidence found either way
The organisation's statement about maintaining additional capacity in 2024/25 is not addressed in the provided sources.
“This federal investment will* *help South Dakota's rural ambulance crews reach patients faster, share critical health data with hospitals, and respond to emergencies with modern technology”
“The Trump Administration announced today that an $8.7 million investment is being delivered to support rural healthcare for Montana residents through the federal Rural Health Transformation Program (RHTP)”
“Professional Sports Authenticator parent company Collectors is investing $200M into the company to "expand operations over the next 18 months."”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“In 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%.”
What happened next: No evidence found either way
The sources do not provide information about whether the promised 2023/24 improvement in Category 2 ambulance response times was achieved.
“We use essential cookies to make our site work.”
“The NHS Alliance homepage”
No evidence found does not mean the action did not happen.
Stated action · timescale: 28 September
“NHS England has undertaken or been involved in several initiatives and activities around imaging reports to improve processes across Trusts and stakeholder organisations”
What happened next: No evidence found either way
The sources discuss radiology initiatives, data sharing improvements, and imaging network development within the NHS, but none confirm or deny specific actions related to imaging reports undertaken by NHS England by 28 September.
“Radiology and diagnostic services are vital to almost every specialty in the NHS, to ensure patients receive high-quality, effective and timely treatment and care. The NHS carries out more than 43 million radiological procedures annually (2018/19) providing X-rays, ultrasound, magnetic resonance imaging (MRI), fluoroscopy and computed axial tomography (CT), and also intervention radiology (IR), to”
“NHS expands 'prescription ready' service to smartwatches and mobiles”
“Improving data sharing between acute hospitals in England: an overview of health record system distribution and retrospective observational analysis of inter-hospital transitions of care”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery”
What happened next: No evidence found either way
NHS England has not provided a specific timeline for addressing ambulance response pressures beyond its general focus on improving performance during 2023/24.
“Escambia County Emergency Medical Services](/story/news/local/escambia-county/2024/02/06/escambia-ems-leaders-vote-no-confidence-in-chief-david-torsell/72480321007/) is making some changes to improve patient safety including purchasing nearly $2 million dollars in new equipment and approving new agreements with local healthcare”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2023/24
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
What happened next: No evidence found either way
No source confirms that £200 million was allocated to ambulance services in 2023/24 for expansion and response improvements.
“Trump Administration announced $7.2 million in Rural Health Transformation Program (RHTP) funding to modernize emergency medical services (EMS) for South Dakota. This investment will provide first responders with modern telemedicine tools, expanded training, and faster access to patient data, helping them respond to emergencies and better connect rural patients with care across South Dakota.”
“This article considers how to reliably provide emergency medical services (EMS). EMS responses are critical functions of local governments, yet, in rural areas, many are staffed by licensed volunteers. As requests for emergency health services increase and the workforce decreases, transitioning to a paid workforce is critical to maintaining response capacity. This article discusses the need and”
“February 11, 2025 By[[name redacted] R. [name redacted], MS, RN, NREMT-P](https://www.jems.com/author/daniel-r-gerard-ms-rn/) 15 min read ##”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
What happened next: No evidence found either way
NHS England's plan for urgent and emergency care recovery includes actions to improve ambulance response times, but no source confirms these actions were completed by 2023/24.
No evidence found does not mean the action did not happen.
Stated action
“Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.”
What happened next: No evidence found either way
The response from the Departmental officials indicates that inquiries have been made with NHS England and the West Yorkshire Integrated Care Board regarding actions to improve ambulance response and handover times, but no specific actions or timelines are mentioned.
“The key lines of enquiry (KLOE) for ambulance handover cover six domains. Their purpose is to invite critical review of relevant aspects of ambulance handover, and to identify opportunities to improve care at the interface of the emergency department (ED) or other hospital acute pathway and ambulance service.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlined key actions to”
What happened next: No evidence found either way
NHS England published a recovery plan in January 2023 outlining priorities for ambulance performance during 2023/24, but the provided sources do not confirm specific actions were completed within that timeframe.
“We use essential cookies to make our site work. We'd like to use additional cookies to understand how you use the site and improve our services. You can find details of these and all other cookies in our [cookie policy”
“Ambulance Services should complete the toolkits in Tackling Demand Together (DH 2009) to support analysis of the reasons for increases in demand.”
“Ambulance handover standards Ambulance handover (clinical handover and offload) is reliably completed within 15 minutes of arrival; delays are rare and are the result of an extraordinary peak in demand.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”
What happened next: No evidence found either way
NHS England has prioritised improving ambulance performance during 2023/24, as outlined in its recovery plan for urgent and emergency care published in January 2023.
“ARP is now a specific work stream within the wider Ambulance Improvement Programme, led by NHS England and NHS Improvement.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action · timescale: 9th December 2023
“On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times: Phase 1: Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire Ambulance Service (YAS) staff were instructed to leave.”
What happened next: No evidence found either way
No source confirms the 045 Handover Plan was implemented on 9th December 2023 at Hull Royal Infirmary.
“Construction Handover: Top Methods for Efficient Project Handover”
“Project handoff process: 8 steps for seamless transitions (2026)”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2024/25
“Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers are essential to ensure patients reach definitive care promptly, which includes both those waiting to receive care in the emergency department (ED), and those waiting in the community. NHS England are continuing to work with trusts and services with significant handover challenges at the 'front end', alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient”
What happened next: No evidence found either way
The NHS England statement on handover delays does not specify a completion date or timeframe for addressing excessive delays.
“Although we are no longer seeing a rise in COVID-19 cases, this hasn't stopped emergency calls from increasing, with many ambulance services still under the same level of pressure as during the height of the pandemic.”
“Ambulance handover and turnaround delays are not good for anybody - least of all patients. National policy direction on this issue is clear: long delays in handing patients over from the care of ambulance crews to that of emergency department (ED) staff are detrimental to clinical quality and patient experience, costly to the NHS, and should no longer be accepted”
“Ambulance handover (clinical handover and offload) is reliably completed within 15 minutes of arrival; delays are rare and are the result of an extraordinary peak in demand.”
No evidence found does not mean the action did not happen.
Stated action
“The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2025/26
“NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services.”
What happened next: No evidence found either way
NHS England has outlined plans to improve urgent and emergency care, including ambulance response times, with a focus on the 2025/26 timeframe.
“We use essential cookies to make our site work.”
“The Urgent & Emergency Care Plan 2025/26: Evolution, Promise & Challenges By [Stevan Bruijns](https://www.stemlynsblog.org/author/scbruijns/ "View all posts by Stevan Bruijns") / June 13, 2025 / [Emergency Department Management](https://www.stemlynsblog”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2025-26
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
What happened next: No evidence found either way
The NHS has set targets for ambulance handover times within 15 minutes and no longer than 45 minutes, and aims to improve 'hear and treat' services, as outlined in its 2025/26 plan.
“joint working arrangements that ensure that no handover takes longer than 45 minutes, working towards delivering handovers within 15 minutes.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No published response from NHS England was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2024 | 0.80 | 0.21 | Closely related · 0.90 | different |
| 2023 → 2024 | 0.74 | 0.15 | Closely related · 0.90 | different |
| 2023 → 2024 | 0.80 | 0.19 | Identical · 0.92 | different |
| 2016 → 2024 | 0.81 | 0.19 | Closely related · 0.90 | different |
| 2016 → 2024 | 0.83 | 0.19 | Closely related · 0.90 | different |
| 2023 → 2024 | 0.67 | 0.21 | Identical · 0.90 | different |
| 2024 → 2024 | 0.73 | 0.15 | Identical · 0.90 | different |
| 2023 → 2024 | 0.62 | 0.19 | Closely related · 0.80 | different |
| 2016 → 2024 | 0.79 | 0.09 | Closely related · 0.90 | different |
| 2024 → 2024 | 0.82 | 0.17 | Identical · 0.94 | different |
| 2023 → 2024 | 0.76 | 0.14 | Identical · 0.90 | different |
| 2024 → 2024 | 0.78 | 0.10 | Closely related · 0.90 | different |
| 2024 → 2025 | 0.86 | 0.24 | Identical · 0.95 | different |
| 2016 → 2025 | 0.86 | 0.15 | Closely related · 0.90 | different |
| 2024 → 2025 | 0.79 | 0.09 | Closely related · 0.90 | different |
| 2024 → 2025 | 0.77 | 0.12 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.68 | 0.18 | Closely related · 0.90 | different |
| 2016 → 2025 | 0.74 | 0.17 | Identical · 0.95 | different |
| 2024 → 2025 | 0.78 | 0.31 | Identical · 0.90 | different |
| 2024 → 2025 | 0.71 | 0.21 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.61 | 0.17 | Closely related · 0.90 | different |
| 2024 → 2025 | 0.67 | 0.16 | Identical · 0.90 | different |
| 2024 → 2026 | 0.76 | 0.22 | Identical · 0.92 | different |
| 2016 → 2026 | 0.86 | 0.11 | Identical · 0.90 | different |
| 2024 → 2026 | 0.78 | 0.22 | Identical · 0.90 | different |
| 2024 → 2026 | 0.79 | 0.14 | Identical · 0.95 | different |
| 2016 → 2026 | 0.85 | 0.26 | Identical · 0.92 | different |
| 2025 → 2026 | 0.87 | 0.26 | Closely related · 0.90 | different |
| 2024 → 2026 | 0.76 | 0.17 | Identical · 0.90 | different |
| 2024 → 2026 | 0.74 | 0.14 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
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- Inadequate medical documentation oversight2 reports · 2024–2026
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- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.