Jade Griffiths-Jones
This report repeats 8 earlier warnings, and was raised again 9 times later. See the linked reports.
The coroner's concerns
1. ambulance crew availability compromised by hospital delays
“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”
2. category 2 ambulance response delay
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
3. hospital delays impact ambulance resourcing
“Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times”
4. insufficient ambulance resources relative to demand
“3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
5. failure to meet response time targets
“West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC”
6. hospital handover delays prevent target response achievement
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
Linked reports
Earlier report
“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.”
This report
“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.”
Earlier report
“I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report”
This report
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Earlier report
“target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust's average response”
This report
“West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.”
Earlier report
“The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time.”
This report
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Earlier report
“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
This report
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
This report
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Earlier report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
This report
“first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised.”
Earlier report
“The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.”
This report
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
This report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
Later report
“The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.”
This report
“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 report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
This report
“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 report
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
This report
“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 report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
This report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.”
Later report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
This report
“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 report
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service”
This report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
Later report
“On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances”
This report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
Later report
“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.”
This report
“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 report
“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.”
Responses
2024-0201-Response-from-DHSC.pdf ↗· NHS England
Stated action · 2023/24
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
2024-0201-Response-from-NHS-Birmingham-and-Solihull.pdf ↗· Department of Health and Social Care
2024-0201-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2023/24
“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.”