Susan Dear

1. 1. unavailable ambulance

   “no missed opportunity to send an ambulance during the time that [the deceased] was waiting overnight on 3 to 4 January 2023 as none was available”

2. 2. delayed ambulance response

   “overnight between 3-4 January 2023 patient's lives were put at risk because SCAS did not have ambulances available to meet the level of demand resulting in severe delay and ambulance response times far outside the national expected standards”

3. 3. chronic resource shortage

   “continuing risk that demand for emergency ambulances would outstrip resources and SCAS were unable to reassure me this was a situation that had been resolved”

4. 4. insufficient capacity improvement

   “SCAS wide improvement programme which is aimed at increasing capacity, which is monitored by NHS England and the Trust's own commissioners”

5. 5. staffing shortage

   “service was operating at under the number of planned staff for that night, (despite the service taking all reasonable steps to meet requirements) due to chronic understaffing of the service with recruitment and retention issues with paramedic and other emergency response staff that the inquest heard are problems nationally”

6. 6. handover delays

   “handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in”

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