Recurance · prevention of future deaths reports
Pre-inquest brief
Ambulance handover delay due to hospital capacity issues
The earlier warning
Ceriann Richards · 1 Mar 2017 · Andrew Barkley, South Wales Central
“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”
judiciary.uk/prevention-of-future-death-reports/ceriann-richards
What was promised
Stated action 1 · response to Ceriann Richards (1 Mar 2017) · stated timescale: none stated
“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 2 · response to Joseph Cattle (22 Feb 2024) · stated timescale: none stated
“I have directed each LHB to develop a local 'six goals' programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities.”
Stated action 3 · response to Peter Parker (22 Oct 2024) · stated timescale: December 2024
“Welsh Government has set a priority for improvement in patient flow and the reduction of delayed discharges (pathways of care delays). To build on this, the Welsh Government has also set health boards in-year aspirations in 2024/2025 to reduce ambulance patient handovers over 1 hour by 30% by December 2024”
1 further stated action is listed on the full chain page.
What recurred
- 22 Feb 2024 · Joseph Cattle · Gavin Knox · Identical hazard · confidence 0.90 (high)
- 22 Oct 2024 · Peter Parker · Aled Gruffydd · Closely related · confidence 0.90 (high)
- 29 May 2025 · Jeanette Sidlow Beech · Kate Robertson · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Joseph Cattle · 22 Feb 2024
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
Later · Jeanette Sidlow Beech · 29 May 2025
“Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.”
What happened next
No web check of the stated actions has been published for this chain.