Roman Barr
4 Mar 2026 · Coroner Linda Lee · Coventry
This report repeats 14 earlier warnings. See the linked reports.
The coroner's concerns
1. overuse of salbutamol inhaler
“Limited awareness of salbutamol overuse”
2. reliever overuse not identified
“Identification and follow-up of reliever overuse”
3. ambulance handover delays
“Ambulance handover delays affecting emergency availability”
4. family transport of critically unwell patient
“Risks when families transport critically unwell patients”
5. NHS Pathways triage wording unclear
“Clarity of NHS Pathways triage wording”
Linked reports
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.”
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.”
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.”
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.”
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.”
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.”
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.”
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.”
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.”
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.”
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
“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.”
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.”
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.”
Closely relatedConfidence 0.90 · high
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
This report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”
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.”
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.”
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.”
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.”
Closely relatedConfidence 0.92 · high
Earlier report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
This report
“Ambulance handover delays affecting emergency availability”
Identical hazardConfidence 0.90 · high
Earlier report
“Significant handover delays leading to ambulance resources being tied up at hospital”
This report
“Ambulance handover delays affecting emergency availability”
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”
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.”
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.”
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.”