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recurance

Peter Scott

26 May 2016 · Coroner Heidi Connor · Nottinghamshire

This report repeats 1 earlier warning, and was raised again 17 times later. See the linked reports.

The coroner's concerns

  1. 1. insufficient ambulance resources

    “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.”
  2. 2. risk of future deaths

    “I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.”
  3. 3. delayed patient handover

    “Consideration should be given to strategies to improve handover times at hospitals.”

Linked reports

Repeats an earlier warningBarbara Patterson21 May 2015 · 1 year earlier
Closely relatedConfidence 0.85 · 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

“Consideration should be given to strategies to improve handover times at hospitals.”
Full chain: Delayed ambulance handover at hospitals
Raised again laterDiana Gudgeon9 Jan 2019 · 2 years 7 months later
Closely relatedConfidence 0.85 · high

This report

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

Later report

“The shortage of double crewed ambulances and fast response vehicles in the Northampton Division.”
Original on judiciary.uk ↗
Full chain: Insufficient ambulance resources in specific division
Raised again laterGordon Gillott4 Feb 2020 · 3 years 8 months later
Closely relatedConfidence 0.90 · high

This report

“I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.”

Later report

“there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues.”
Original on judiciary.uk ↗
Full chain: Ambulance resource shortage delays urgent patient transfers
Raised again laterRita Taylor25 Jan 2023 · 6 years 8 months later
Identical hazardConfidence 0.90 · high

This report

“I remain very concerned about resource issues for this ambulance service.”

Later report

“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Original on judiciary.uk ↗
Full chain: Insufficient ambulance availability leading to delayed response
Raised again laterChristopher Hart9 Nov 2023 · 7 years 5 months later
Identical hazardConfidence 0.90 · high

This report

“I remain very concerned about resource issues for this ambulance service.”

Later report

“continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life”
Original on judiciary.uk ↗
Full chain: Insufficient ambulance availability leading to delayed response
Raised again laterLynda Blackmore15 Nov 2023 · 7 years 6 months later
Closely relatedConfidence 0.90 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterKenneth Heard23 Nov 2023 · 7 years 6 months later
Closely relatedConfidence 0.85 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterDavid Briggs1 Dec 2023 · 7 years 6 months later
Identical hazardConfidence 0.85 · high

This report

“I remain very concerned about resource issues for this ambulance service.”

Later report

“YAS were not resourced to respond to the number of emergency calls.”
Original on judiciary.uk ↗
Full chain: Insufficient ambulance availability leading to delayed response
Raised again laterJade Griffiths-Jones17 Apr 2024 · 7 years 11 months later
Closely relatedConfidence 0.90 · high

This report

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

Later 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”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 8 years 1 month later
Closely relatedConfidence 0.85 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. 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.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterColin Wiles24 Nov 2024 · 8 years 6 months later
Closely relatedConfidence 0.90 · high

This report

“Consideration should be given to strategies to improve handover times at hospitals.”

Later report

“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterNicola Owens31 Jan 2025 · 8 years 8 months later
Closely relatedConfidence 0.90 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later 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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterDiana Fairweather-Purkis17 Feb 2025 · 8 years 9 months later
Identical hazardConfidence 0.95 · high

This report

“I remain very concerned about resource issues for this ambulance service.”

Later report

“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterBrian Garrick30 May 2025 · 9 years later
Identical hazardConfidence 0.98 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

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 · 9 years 3 months later
Closely relatedConfidence 0.90 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterLewis Garfield28 Oct 2025 · 9 years 5 months later
Closely relatedConfidence 0.90 · high

This report

“one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes.”
Original on judiciary.uk ↗
Full chain: Delayed ambulance handover at hospitals
Raised again laterRoman Barr4 Mar 2026 · 9 years 9 months later
Identical hazardConfidence 0.90 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

Later report

“3. 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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays
Raised again laterRoman Barr3 Apr 2026 · 9 years 10 months later
Identical hazardConfidence 0.92 · high

This report

“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at 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.”
Original on judiciary.uk ↗
Full chain: Ambulance crew availability reduced by hospital handover delays

Responses

2016-0199-Response-by-East-Midlands-Ambulance-Service.pdf ↗· East Midlands Ambulance Service

Stated action · 2016/17

“EMAS has taken the CQC findings seriously and value the additional support from other NHS organisations following the CQC Quality Summit. With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS' immediate control.”

2016-0199-Response-by-NHS-England.pdf ↗· NHS England

Stated action · 2016/17 contract

“The need for an urgent review of resources to reduce the risk of future deaths”

2016-0199-Response-by-NHS-Improvment.pdf ↗· NHS Hardwick

Stated action

“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
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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