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recurance

Roman Barr

4 Mar 2026 · Coroner Linda Lee · Coventry

This report repeats 14 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. overuse of salbutamol inhaler

    “Limited awareness of salbutamol overuse”
  2. 2. reliever overuse not identified

    “Identification and follow-up of reliever overuse”
  3. 3. ambulance handover delays

    “Ambulance handover delays affecting emergency availability”
  4. 4. family transport of critically unwell patient

    “Risks when families transport critically unwell patients”
  5. 5. NHS Pathways triage wording unclear

    “Clarity of NHS Pathways triage wording”

Linked reports

Repeats an earlier warningBarbara Patterson21 May 2015 · 10 years 9 months earlier
Identical hazardConfidence 0.95 · 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

“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.”
Full chain: Ambulance handover delays at hospitals reduce availability
Repeats an earlier warningPeter Scott26 May 2016 · 9 years 9 months earlier
Identical hazardConfidence 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.”
Original on judiciary.uk ↗

This 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.”
Full chain: Ambulance crew availability reduced by hospital handover delays
Repeats an earlier warningAlexander Davidson2 May 2019 · 6 years 10 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child.”
Original on judiciary.uk ↗

This report

“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Full chain: Unclear wording in NHS Pathways triage questions
Repeats an earlier warningLynda Blackmore15 Nov 2023 · 2 years 4 months earlier
Identical hazardConfidence 0.94 · 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.”
Original on judiciary.uk ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJohn Seagrove, Pauline Humphris and Patricia Steggles23 Nov 2023 · 2 years 3 months earlier
Identical hazardConfidence 0.92 · high

Earlier report

“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Original on judiciary.uk ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJade Griffiths-Jones17 Apr 2024 · 1 year 11 months earlier
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”
Original on judiciary.uk ↗

This 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.”
Full chain: Ambulance crew availability reduced by hospital handover delays
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 1 year 8 months earlier
Identical hazardConfidence 0.95 · high

Earlier report

“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
Original on judiciary.uk ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningKevin Woods3 Oct 2024 · 1 year 5 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Original on judiciary.uk ↗

This report

“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningColin Wiles24 Nov 2024 · 1 year 3 months earlier
Identical hazardConfidence 0.92 · high

Earlier 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 ↗

This 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.”
Full chain: Ambulance crew availability reduced by hospital handover delays
Repeats an earlier warningNicola Owens31 Jan 2025 · 1 year 1 month earlier
Identical hazardConfidence 0.90 · high

Earlier 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 ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningLachlan Campbell (2)28 Feb 2025 · 1 year earlier
Closely relatedConfidence 0.92 · high

Earlier report

“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Original on judiciary.uk ↗

This report

“Ambulance handover delays affecting emergency availability”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningAndrew Waters3 Apr 2025 · 11 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“Significant handover delays leading to ambulance resources being tied up at hospital”
Original on judiciary.uk ↗

This report

“Ambulance handover delays affecting emergency availability”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningBernard Lyon9 Apr 2025 · 11 months earlier
Identical hazardConfidence 0.95 · high

Earlier report

“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”
Original on judiciary.uk ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJames Smith12 May 2025 · 10 months earlier
Identical hazardConfidence 0.95 · high

Earlier report

“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Original on judiciary.uk ↗

This 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.”
Full chain: Delayed ambulance handover at hospitals

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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.

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