Recurance · prevention of future deaths reports
Pre-inquest brief
Ambulance handover delays at hospitals reduce availability
The earlier warning
Barbara Patterson · 21 May 2015 · Carly Henley, Northumberland (North)
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
What was promised
Stated action 1 · response to Barbara Patterson (21 May 2015) · stated timescale: September 2015
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
judiciary.uk/…/2015-0198-Response-by-Care-Quality-Commission.pdf
What recurred
- 4 Mar 2026 · Roman Barr · Linda Lee · Identical hazard · confidence 0.95 (high)
- 3 Apr 2026 · Roman Barr · Linda Lee · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Barbara Patterson · 21 May 2015
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“Safe staffing in care is all about having enough staff who have the correct skills and values to deliver high-quality care and support to service users.”
Guide to Safe Staffing and Regulations in Care | Access Group · theaccessgroup.com/…/hsc-guide-to-safe-staffing-and-regulations…
No evidence found does not mean the action did not happen.