Insufficient ambulance resources leading to delayed response
South East Coast Ambulance Service received 4 coroners' reports about this hazard between 27 Feb 2018 and 26 Jun 2023.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“the ambulance was so delayed in its response to Mr [name redacted]”
Original on judiciary.uk ↗ South East Coast Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”
- 4 months later
“(1) That there were insufficient resources to deal with the high number of calls on”
Original on judiciary.uk ↗ South East Coast Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”
Stated timescale: next three years
- 4 years 9 months laterClosely relatedConfidence 0.92 · higha different coroner
“There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”
Original on judiciary.uk ↗ South East Coast Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“SECAmb had planned for 2370.1 WTE by 31 March 2023.”
Stated timescale: 31 March 2023
- 3 months laterClosely relatedConfidence 0.85 · higha different coroner
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources”
Original on judiciary.uk ↗ South East Coast Ambulance Service responded.Response (PDF) ↗Response (PDF) ↗
- All reports to South East Coast Ambulance Service
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.
2018 → 2023Veronica Jenkins4 years 9 months after Margaret Stemp · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight that a shortage of staff or resources leads to dangerous delays in ambulance response and patient care. The earlier case describes patients left unattended for hours due to insufficient resources; the later case warns of delayed response times from a deficit in operational hours caused by lack of staff.
Margaret Stemp · 25 Jun 2018
“(1) That there were insufficient resources to deal with the high number of calls on”
Original on judiciary.uk ↗ Veronica Jenkins · 31 Mar 2023
“There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”
2018 → 2023Veronica Jenkins5 years 1 month after Kevan Funnell · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports identify delayed ambulance response times as a safety risk. The earlier case focuses on a single incident due to call grading and follow‑up failures; the later case highlights systemic staff shortages and hospital handover delays causing ongoing delays.
Kevan Funnell · 27 Feb 2018
“the ambulance was so delayed in its response to Mr [name redacted]”
Original on judiciary.uk ↗ Veronica Jenkins · 31 Mar 2023
“a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”
2018 → 2023Ginger Wright5 years after Margaret Stemp · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that insufficient ambulance resources lead to dangerous delays in patient care. The earlier case describes a specific incident where low staffing left patients unattended for hours; the later warning notes routine operation at surge capacity that risks repeating such delays.
Margaret Stemp · 25 Jun 2018
“there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours”
Original on judiciary.uk ↗ Ginger Wright · 26 Jun 2023
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”
2018 → 2023Ginger Wright5 years 4 months after Kevan Funnell · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight delays in ambulance response due to insufficient resources relative to demand.
Kevan Funnell · 27 Feb 2018
“the ambulance was so delayed in its response to Mr [name redacted]”
Original on judiciary.uk ↗ Ginger Wright · 26 Jun 2023
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”
Stated action
“We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”
Stated action · timescale: next three years
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”
Stated action · timescale: 31 March 2023
“SECAmb had planned for 2370.1 WTE by 31 March 2023.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 South East Coast Ambulance Service 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 |
|---|---|---|---|---|
| 2018 → 2023 | 0.65 | 0.02 | Closely related · 0.92 | different |
| 2018 → 2023 | 0.75 | 0.12 | Closely related · 0.85 | different |
| 2018 → 2023 | 0.66 | 0.04 | Closely related · 0.85 | different |
| 2018 → 2023 | 0.67 | 0.01 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.