Lee Dryden
2 Aug 2023 · Coroner Abigail Combes · South Yorkshire (West District)
This report repeats 1 earlier warning, and was raised again 8 times later. See the linked reports.
The coroner's concerns
1. inconsistent reporting of images from external organisations to NHS Trusts
“There is Royal College Guidance as to how and by what means the images are reported from external organisations such as Medical Alliance to NHS Trusts however this appears to not be understood or embedded by NHS Trusts.”
2. delayed ambulance response to Lee Dryden
“The Ambulance Service graded [the deceased]'s mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded too within 40 minutes. 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].”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”
This report
“2. The Ambulance Service graded [the deceased]'s mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded too within 40 minutes. 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”
Closely relatedConfidence 0.90 · high
This report
“significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
Later 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
This 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].”
Later 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.”
Identical hazardConfidence 0.92 · high
This report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
Later report
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Identical hazardConfidence 0.90 · high
This report
“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].”
Later report
“They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.”
Identical hazardConfidence 0.90 · high
This 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].”
Later report
“Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr [name redacted] death, still remain outside of the target response standards (both on average and at the 90th centile).”
Closely relatedConfidence 0.80 · moderate
This report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
Later report
“notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Identical hazardConfidence 0.90 · high
This 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].”
Later report
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Closely relatedConfidence 0.90 · high
This report
“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].”
Later report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Responses
2025-0402-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action
“In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”
Stated action · 2024/25
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
Stated action · 2023/24
“In 2023/24, average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were over 13 minutes faster compared to the previous year, a reduction of 27%.”
2025-0402-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 28 September
“NHS England has undertaken or been involved in several initiatives and activities around imaging reports to improve processes across Trusts and stakeholder organisations”