Nicola Owens
31 Jan 2025 · Coroner Anita Bhardwaj · Liverpool and Wirral
This report repeats 10 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. ambulance delay due to unavailability and handover delays
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing”
Linked reports
Closely relatedConfidence 0.90 · 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.”
This report
“This delay being significantly contributed to by the handover delays in hospitals.”
Closely relatedConfidence 0.90 · high
Earlier report
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Closely relatedConfidence 0.90 · high
Earlier report
“delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Closely relatedConfidence 0.90 · high
Earlier report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Repeats an earlier warningJohn Seagrove, Pauline Humphris and Patricia Steggles23 Nov 2023 · 1 year 2 months earlier
Closely relatedConfidence 0.80 · moderate
Earlier report
“During the course of these inquests, the evidence has revealed matters giving rise to concern.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Closely relatedConfidence 0.90 · high
Earlier report
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing”
Closely relatedConfidence 0.90 · high
Earlier report
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Identical hazardConfidence 0.95 · high
Earlier 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”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Closely relatedConfidence 0.90 · high
Earlier report
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 7 months earlier
Identical hazardConfidence 0.90 · high
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Closely relatedConfidence 0.90 · high
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
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.”
Identical hazardConfidence 0.90 · high
This report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Later report
“Ambulance handover delays affecting emergency availability 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.”
Closely relatedConfidence 0.90 · high
This report
“This delay being significantly contributed to by the handover delays in hospitals.”
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
2025-0053-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · 2025-26
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
2025-0053-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2025/26
“NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services.”