Jean Walker
20 Mar 2024 · Coroner Hannah Berry · South Yorkshire West
This report repeats 3 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance response
“The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
2. offloading delay
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
This report
“The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
Closely relatedConfidence 0.90 · high
Earlier report
“significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
This report
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence was heard as to the very high call demand overnight on 6t h and ih August 2022 and with regard to the number of ambulances waiting at Hospitals in the region to hand over patients”
This report
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”
Identical hazardConfidence 0.90 · high
This report
“The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
Later report
“I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024).”
Identical hazardConfidence 0.90 · high
This report
“The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
Later report
“Despite the urgency with which an ambulance was required for Mr [name redacted] no ambulance resource was available.”
Responses
2024-0158-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · shortly
“the West Yorkshire Integrated Care Board will shortly be responding on the specific local actions being taken to support ambulance response times”
2024-0158-Response-from-West-Yorkshire-ICB.pdf ↗· West Yorkshire Integrated Care Board