Excessive ambulance handover delays at hospitals
Welsh Ambulance Service NHS Trust received 3 coroners' reports about this hazard between 1 Mar 2017 and 15 Nov 2023.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals”
Original on judiciary.uk ↗ Welsh Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“a Health Board we have implemented and reviewed a number of key processes. e An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives. The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing”
Stated timescale: 20 April 2017
- 6 years 4 months later
Raised again · 1st time
Leonard Harmsworth↗
20 Jun 2023 · Kate Sutherland · North Wales East and Central
Identical hazardConfidence 0.90 · higha different coroner“On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”
Original on judiciary.uk ↗ No published response from Welsh Ambulance Service NHS Trust was found for this report.
- 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Original on judiciary.uk ↗ Repeated from the earlier report:evidencedelaysexperienced
Welsh Ambulance Service NHS Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
Web search (Tavily): No evidence found either way
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
Stated timescale: January 2024
Web search (Tavily): No evidence found either way
Annual Report and Accounts 2023/24 ↗ - All reports to Welsh Ambulance Service NHS Trust
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.
2017 → 2023Leonard Harmsworth6 years 4 months after Ceriann Richards · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight excessive ambulance handover delays at hospitals as the core problem. These delays reduce ambulance availability and lead to prolonged response times for patients.
Ceriann Richards · 1 Mar 2017
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
Original on judiciary.uk ↗ Leonard Harmsworth · 20 Jun 2023
“On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”
Original on judiciary.uk ↗ 2017 → 2023Lynda Blackmore6 years 8 months after Ceriann Richards · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify ambulance handover delays at hospitals as the cause of delayed ambulance response to patients needing emergency care. The later report reiterates that these delays exceed national targets and affect response times.
Ceriann Richards · 1 Mar 2017
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals”
Original on judiciary.uk ↗ Lynda Blackmore · 15 Nov 2023
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service's ability to respond to subsequent calls in the community, but also on patient's experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital”
Stated action · timescale: 20 April 2017
“a Health Board we have implemented and reviewed a number of key processes. e An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives. The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing”
No published response from Welsh Ambulance Service NHS Trust was found for this report.
Stated action
“We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
What happened next: No evidence found either way
The organisation's statement about producing guidelines for fever in under 5s, sepsis, and sore throat is not supported by any source evidence.
No evidence found does not mean the action did not happen.
Stated action · timescale: January 2024
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
What happened next: No evidence found either way
The Welsh Ambulance Service NHS Trust outlined plans to implement measures in January 2024 to reduce patient conveyances to The Grange Hospital through alternative admissions and a new temporary facility. No source confirms these actions were completed or operational by January 2024.
“It will provide the reader with detail on the Trust's performance and how we responded to changing demands and challenges in 2023/24.”
“Summary ............................................................................................................................ 5 Background ........................................................................................................................ 5 999 Emergency Medical Services ...................................................................................... 7 Remote”
“Document Title: Planning to Safely Reduce Avoidable Conveyance Publishing approval number: Version number: 01 First published: 22 July 2019 Updated: Prepared by: [name redacted]: OFFICIAL This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact the Central Ambulance Team”
No evidence found does not mean the action did not happen.
- 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 Welsh Ambulance Service NHS Trust 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 |
|---|---|---|---|---|
| 2017 → 2023 | 0.77 | 0.09 | Identical · 0.90 | different |
| 2017 → 2023 | 0.75 | 0.14 | Closely related · 0.90 | 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.