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recurance

Jade Griffiths-Jones

17 Apr 2024 · Coroner Emma Brown · Birmingham and Solihull

This report repeats 8 earlier warnings, and was raised again 9 times later. See the linked reports.

The coroner's concerns

  1. 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. 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. 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. 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. 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. 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

Repeats an earlier warningBarbara Patterson21 May 2015 · 8 years 11 months earlier
Identical hazardConfidence 0.95 · high

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.”
Original on judiciary.uk ↗

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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningPeter Scott26 May 2016 · 7 years 11 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report”
Original on judiciary.uk ↗

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”
Full chain: Ambulance crew availability reduced by hospital handover delays
Repeats an earlier warningGrenville Wait24 Jun 2022 · 1 year 10 months earlier
Identical hazardConfidence 0.90 · high

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”
Original on judiciary.uk ↗

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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningIrene Davies14 Sept 2022 · 1 year 7 months earlier
Closely relatedConfidence 0.85 · high

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.”
Original on judiciary.uk ↗

This report

“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningRita Taylor25 Jan 2023 · 1 year 3 months earlier
Identical hazardConfidence 0.92 · high

Earlier report

“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
Original on judiciary.uk ↗

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”
Full chain: Insufficient ambulance availability leading to delayed response
Repeats an earlier warningMichael Bray22 May 2023 · 11 months earlier
Identical hazardConfidence 0.92 · high

Earlier report

“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Original on judiciary.uk ↗

This report

“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningLee Dryden2 Aug 2023 · 9 months earlier
Closely relatedConfidence 0.90 · high

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].”
Original on judiciary.uk ↗

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.”
Full chain: Ambulance crew availability reduced by hospital handover delays
Repeats an earlier warningGeoffery Hoad13 Sept 2023 · 7 months earlier
Identical hazardConfidence 0.90 · high

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.”
Original on judiciary.uk ↗

This report

“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Full chain: Delayed ambulance handover at hospitals
Raised again laterHenry Willems21 Oct 2024 · 6 months later
Identical hazardConfidence 0.90 · high

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.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterNicola Owens31 Jan 2025 · 9 months later
Identical hazardConfidence 0.95 · high

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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterDiana Fairweather-Purkis17 Feb 2025 · 10 months later
Identical hazardConfidence 0.90 · high

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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterLachlan Campbell (2)28 Feb 2025 · 10 months later
Identical hazardConfidence 0.95 · high

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”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterJames Smith12 May 2025 · 1 year 1 month later
Identical hazardConfidence 0.95 · high

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.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterBrian Garrick30 May 2025 · 1 year 1 month later
Closely relatedConfidence 0.90 · high

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”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterRicky O'Connell20 Aug 2025 · 1 year 4 months later
Identical hazardConfidence 0.90 · high

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”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterRoman Barr4 Mar 2026 · 1 year 11 months later
Identical hazardConfidence 0.90 · high

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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterRoman Barr3 Apr 2026 · 2 years later
Identical hazardConfidence 0.95 · high

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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays

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-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.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error