Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Christopher Fields · 18 May 2016 · John Pollard, Manchester South
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
What was promised
Stated action 1 · response to Christopher Fields (18 May 2016) · stated 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”
Stated action 2 · response to Peter Scott (26 May 2016) · stated timescale: none stated
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
Stated action 3 · response to Peter Scott (26 May 2016) · stated timescale: 2016/17 contract
“The need for an urgent review of resources to reduce the risk of future deaths”
15 further stated actions are listed on the full chain page.
What recurred
- 26 May 2016 · Peter Scott · Heidi Connor
- 20 Jul 2023 · Albert Dovey · Alison Mutch
- 2 Aug 2023 · Lee Dryden · Abigail Combes
- 15 Jan 2024 · Dennis King · Darren Stewart
- 17 Apr 2024 · Jade Griffiths-Jones · Emma Brown · Closely related · confidence 0.90 (high)
- 29 Apr 2024 · Sophie Hindmarsh · Hannah Berry · Identical hazard · confidence 0.92 (high)
- 3 May 2024 · Michael Clarke · Alison Mutch · Closely related · confidence 0.90 (high)
- 15 Jul 2024 · Josh Smith · Jessica Swift · Identical hazard · confidence 0.90 (high)
- 6 Nov 2024 · Simon Boyd · Chris Morris · Identical hazard · confidence 0.90 (high)
- 24 Nov 2024 · Colin Wiles · Sally Robinson · Closely related · confidence 0.90 (high)
- 19 Dec 2024 · Andrew Lewis · Heidi Connor · Identical hazard · confidence 0.94 (high)
- 31 Jan 2025 · Nicola Owens · Anita Bhardwaj · Identical hazard · confidence 0.95 (high)
- 17 Feb 2025 · Diana Fairweather-Purkis · Paul Appleton · Identical hazard · confidence 0.95 (high)
- 4 Mar 2026 · Roman Barr · Linda Lee · Identical hazard · confidence 0.92 (high)
- 3 Apr 2026 · Roman Barr · Linda Lee · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · Nicola Owens · 31 Jan 2025
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
What happened next
No evidence found either way · stated action 1
“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,”
Ambulance Response Programme Clinical Coding Tria · england.nhs.uk/…/letter-dh-wmas-coding-trial.pdf
No evidence found does not mean the action did not happen.
Evidence found · stated action 2
“The trust's "turnaround plan" lists measures including recruiting more paramedics, tackling sickness and restructuring management.”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
“The trust said it planned to recruit 82 specialist paramedics, 149 paramedics, 24 emergency medical technicians and 96 emergency care assistants.”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
“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,”
East of England Ambulance: Plan to recruit 350 staff · bbc.com/news/uk-england-22252375
No evidence found either way · stated action 3
“Capacity pressures in health and social care in England”
Capacity pressures in health and social care in England · commonslibrary.parliament.uk/…/capacity-pressures-in-health-and…
“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”
Ambulance Response Programme Review · england.nhs.uk/…/ambulance-response-programme-review.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”
“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].”
Quality Standard for Imaging - College of Radiographers · collegeofradiographers.ac.uk/…/qsi_standards-2024.pdf
“The regional medical imaging interoperability network which serves 4-Million patients throughout Yorkshire, the Humber and North Lincolnshire”
About our network - Yorkshire Imaging Collaborative · yorkshireimaging.nhs.uk/about-our-network
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“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”
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS · cms.gov/…/trump-administration-announces-7-2-million-expand-amb…
“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)”
Trump Administration Announces $8.7 Million for New Ambulances and Lifesaving Medical Equipment Upgrades Across Rural Montana | CMS · cms.gov/…/trump-administration-announces-8-7-million-new-ambula…
“Professional Sports Authenticator parent company Collectors is investing $200M into the company to "expand operations over the next 18 months."”
PSA parent Collectors invests $200M to expand operations · sportsbusinessjournal.com/…/psa-parent-collectors-invests-200m-…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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%.”
“We use essential cookies to make our site work.”
Written evidence - AMB0002 · committees.parliament.uk/writtenevidence/165608/html
“The NHS Alliance homepage”
Ambulance sector · thenhsalliance.org/…/ambulance-sector
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “NHS England has undertaken or been involved in several initiatives and activities around imaging reports to improve processes across Trusts and stakeholder organisations”
“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”
Radiology - Getting It Right First Time - GIRFT · gettingitrightfirsttime.co.uk/medical_specialties/radiology
“NHS expands 'prescription ready' service to smartwatches and mobiles”
NHS to transform scan access for 6.6 million people in major tech initiative - Med-Tech Insights · med-techinsights.com/…/nhs-to-transform-scan-access-for-6-6-mil…
“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”
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 · pmc.ncbi.nlm.nih.gov/articles/PMC7008454
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“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”
Escambia County EMS ambulance response times to improve · pnj.com/…/77064995007
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
“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.”
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS · cms.gov/…/trump-administration-announces-7-2-million-expand-amb…
“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”
How Should Rural EMS Funding Streams Be Improved? | Journal of Ethics | American Medical Association · journalofethics.ama-assn.org/…/2025-07
“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 ##”
Optimizing EMS and Reducing Ambulance Patient Offload Time: Part 1 · jems.com/…/optimizing-ems-and-reducing-ambulance-patient-offloa…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
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.
No evidence found either way · 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.”
“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.”
Reducing ambulance handover delays: key lines of enquiry · england.nhs.uk/…/Reducing_ambulance_handover_delays_-_key_lines…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“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 service response times · commonslibrary.parliament.uk/research-briefings/cdp-2025-0042
“Ambulance Services should complete the toolkits in Tackling Demand Together (DH 2009) to support analysis of the reasons for increases in demand.”
Improving Ambulance Handover – Practical Approaches · england.nhs.uk/wp-content/uploads/2013/08/amb-hand.pdf
“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.”
Reducing ambulance handover delays: key lines of enquiry · england.nhs.uk/…/Reducing_ambulance_handover_delays_-_key_lines…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“ARP is now a specific work stream within the wider Ambulance Improvement Programme, led by NHS England and NHS Improvement.”
Ambulance Response Programme (ARP) Impact Assessment · england.nhs.uk/…/ambulance-response-programme-impact-assessment…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“Construction Handover: Top Methods for Efficient Project Handover”
Construction Handover: Top Methods for Efficient Project Handover | Kahua · kahua.com/…/construction-handover-top-methods-for-efficient-pro…
“Project handoff process: 8 steps for seamless transitions (2026)”
Project Handoff Guide: 8 Steps For Smooth Transitions · monday.com/blog/project-management/project-handoff
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“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.”
Reducing ambulance handover delays | Health Spaces 🏥 · health-spaces.com/blog/2022/09/28/ambulance-handover-delays
“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”
Improving Ambulance Handover – Practical Approaches · england.nhs.uk/wp-content/uploads/2013/08/amb-hand.pdf
“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.”
Reducing ambulance handover delays: key lines of enquiry · england.nhs.uk/…/Reducing_ambulance_handover_delays_-_key_lines…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“We use essential cookies to make our site work.”
Ambulance service response times · commonslibrary.parliament.uk/research-briefings/cdp-2025-0042
“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”
The Urgent & Emergency Care Plan 2025/26: Evolution, Promise & Challenges NHS UEC Plan 2025/26: Critical Analysis & Key Changes · stemlynsblog.org/…/the-urgent-emergency-care-plan-2025-26-evolu…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“joint working arrangements that ensure that no handover takes longer than 45 minutes, working towards delivering handovers within 15 minutes.”
The latest update on the W45 / Rapid Release Protocols · aace.org.uk/…/the-latest-update-on-the-w45-rapid-release-protoc…
No evidence found does not mean the action did not happen.