Ricky O'Connell
20 Aug 2025 · Coroner Alison Mutch · Manchester South
This report repeats 12 earlier warnings. See the linked reports.
The coroner's concerns
1. ambulance arrival delay
“adherence to the timescales should have resulted in an ambulance arriving before he collapsed”
2. ED boarding delays
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”
3. service capacity strain
“the ambulance service was generally operating at full stretch due to the demand for their services”
4. inter‑Trust turnaround delays
“all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted”
5. nightshift demand surge
“the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further”
6. hospital handover delays
“prolonged hospital handovers and overall demand on the service”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
This report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
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
“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].”
Identical hazardConfidence 0.95 · high
Earlier report
“The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.”
This report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”
Identical hazardConfidence 0.90 · high
Earlier report
“Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”
This 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.”
Closely relatedConfidence 0.85 · high
Earlier report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
This 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].”
Identical hazardConfidence 0.90 · high
Earlier report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment”
This report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
Closely relatedConfidence 0.85 · high
Earlier report
“The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment”
This report
“The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed.”
Identical hazardConfidence 0.90 · high
Earlier report
“delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.”
This report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”
Identical hazardConfidence 0.90 · high
Earlier 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”
This 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 0.95 · high
Earlier report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”
This report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 1 year 2 months earlier
Closely relatedConfidence 0.90 · high
Earlier report
“Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”
This 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].”
Closely relatedConfidence 0.90 · high
Earlier report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
This 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.”