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recurance

Ambulance crew availability reduced by hospital handover delays

Closely relatedConfidence 0.80 · moderate16 reports · 2016–2026No published response to an earlier report One-page brief (print or PDF)

NHS England received 16 coroners' reports about this hazard between 18 May 2016 and 3 Apr 2026.

They came from 13 different coroners in 12 coroner areas. A similar concern was raised again 15 times after the first warning.

A published response was found for 15 of the 15 earlier reports, stating 18 specific actions.

16
reports
13
different coroners
2016–2026
years
0.80
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Christopher Fields↗

    18 May 2016 · John Pollard · Manchester South

    “In the event, the vehicle did not arrive for 2 hours 8 minutes.”
    Original on judiciary.uk ↗

    NHS England responded, stating 1 specific action.Response (PDF) ↗

    “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the High quality care for all, now and for future generations outcome of previous similar 999 calls as well as the concerns raised by Coroners in Regulation 28 Reports. We anticipate making recommendations in autumn 2016. It is our intention that this review should improve the service provided and clinical outcomes for future patients contacting the 9”

    Stated timescale: autumn 2016

    Web search (Tavily): No evidence found either way

    Ambulance Response Programme Clinical Coding Tria ↗
  2. 0 months later

    Raised again · 1st time

    Peter Scott↗

    26 May 2016 · Heidi Connor · Nottinghamshire

    “I remain very concerned about resource issues for this ambulance service.”
    Original on judiciary.uk ↗

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

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

    Web search (Tavily): Evidence found that the action was carried out

    East of England Ambulance: Plan to recruit 350 staff ↗
    “The need for an urgent review of resources to reduce the risk of future deaths”

    Stated timescale: 2016/17 contract

    Web search (Tavily): No evidence found either way

    Capacity pressures in health and social care in England ↗
  3. 7 years 2 months later

    Raised again · 2nd time

    Albert Dovey↗

    20 Jul 2023 · Alison Mutch · Manchester South

    “delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital.”
    Original on judiciary.uk ↗

    NHS England responded.Response (PDF) ↗

  4. 0 months later

    Raised again · 3rd time

    Lee Dryden↗

    2 Aug 2023 · Abigail Combes · South Yorkshire (West District)

    “Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
    Original on judiciary.uk ↗

    NHS England responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗

    “In addition, all North East & Yorkshire systems have been asked for assurance that national guidance is being followed.”

    Web search (Tavily): No evidence found either way

    Quality Standard for Imaging - College of Radiographers ↗
    “Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”

    Stated timescale: 2024/25

    2 more stated actions in the Promises tab.

  5. 5 months later

    Raised again · 4th time

    Dennis King↗

    15 Jan 2024 · Darren Stewart · Suffolk

    “Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
    Original on judiciary.uk ↗

    NHS England responded, stating 1 specific action.Response (PDF) ↗

    “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery”

    Stated timescale: 2023/24

    Web search (Tavily): No evidence found either way

    Escambia County EMS ambulance response times to improve ↗
  6. 3 months later

    Raised again · 5th time

    Jade Griffiths-Jones↗

    17 Apr 2024 · Emma Brown · Birmingham and Solihull

    Closely relatedConfidence 0.90 · higha different coroner
    “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 ↗

    Repeated from the earlier report:ambulanceresource

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗

    “Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”

    Stated timescale: 2023/24

    “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

    Stated timescale: 2023/24

    Web search (Tavily): No evidence found either way

  7. 0 months later

    Raised again · 6th time

    Sophie Hindmarsh↗

    29 Apr 2024 · Hannah Berry · South Yorkshire West

    Identical hazardConfidence 0.92 · higha different coroner
    “The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:ambulancehoursminutescall

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.”

    Web search (Tavily): No evidence found either way

    Reducing ambulance handover delays: key lines of enquiry ↗
    “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlined key actions to”

    Stated timescale: 2023/24

    Web search (Tavily): No evidence found either way

    Ambulance service response times ↗
  8. 0 months later

    Raised again · 7th time

    Michael Clarke↗

    3 May 2024 · Alison Mutch · Manchester South

    Closely relatedConfidence 0.90 · higha different coroner
    “due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
    Original on judiciary.uk ↗

    NHS England responded, stating 1 specific action.Response (PDF) ↗

    “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”

    Stated timescale: 2023/24

    Web search (Tavily): No evidence found either way

    Ambulance Response Programme (ARP) Impact Assessment ↗
  9. 2 months later

    Raised again · 8th time

    Josh Smith↗

    15 Jul 2024 · Jessica Swift · Kingston upon Hull & East Riding

    Identical hazardConfidence 0.90 · higha different coroner
    “Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr [name redacted] death, still remain outside of the target response standards (both on average and at the 90th centile).”
    Original on judiciary.uk ↗
  10. 4 months later

    Raised again · 9th time

    Simon Boyd↗

    6 Nov 2024 · Chris Morris · Manchester South

    Identical hazardConfidence 0.90 · higha different coroner
    “The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:targetCategorywaitambulancehours

  11. 1 month later

    Raised again · 10th time

    Colin Wiles↗

    24 Nov 2024 · Sally Robinson · City of Kingston Upon Hull and the County of the East Riding of Yorkshire

    Closely relatedConfidence 0.90 · higha different coroner
    “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 ↗

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times: Phase 1: Two weeks targeting a maximum handover time of 80 minutes, after which Yorkshire Ambulance Service (YAS) staff were instructed to leave.”

    Stated timescale: 9th December 2023

    “Excessive hospital handover delays remain a key issue for the NHS. Rapid handovers are essential to ensure patients reach definitive care promptly, which includes both those waiting to receive care in the emergency department (ED), and those waiting in the community. NHS England are continuing to work with trusts and services with significant handover challenges at the 'front end', alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient”

    Stated timescale: 2024/25

    Web search (Tavily): No evidence found either way

    Reducing ambulance handover delays | Health Spaces 🏥 ↗
  12. 1 month later

    Raised again · 11th time

    Andrew Lewis↗

    19 Dec 2024 · Heidi Connor · Berkshire

    Identical hazardConfidence 0.94 · higha different coroner
    “I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:hourshospitals

    NHS England responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗

    “The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published.”
  13. 1 month later

    Raised again · 12th time

    Nicola Owens↗

    31 Jan 2025 · Anita Bhardwaj · Liverpool and Wirral

    Identical hazardConfidence 0.95 · higha different coroner
    “The delay in an ambulance attending patients due to the unavailability of ambulances.”
    Original on judiciary.uk ↗

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services.”

    Stated timescale: 2025/26

    Web search (Tavily): No evidence found either way

    Ambulance service response times ↗
    “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”

    Stated timescale: 2025-26

    Web search (Tavily): No evidence found either way

    The latest update on the W45 / Rapid Release Protocols ↗
  14. 1 month later

    Raised again · 13th time

    Diana Fairweather-Purkis↗

    17 Feb 2025 · Paul Appleton · Teesside and Hartlepool

    Identical hazardConfidence 0.95 · higha different coroner
    “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 ↗

    Repeated from the earlier report:AmbulanceService

  15. 1 year later

    Raised again · 14th time

    Roman Barr↗

    4 Mar 2026 · Linda Lee · Coventry

    Identical hazardConfidence 0.92 · higha different coroner
    “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 ↗

    Repeated from the earlier report:ambulancetimestime

  16. 1 month later

    Raised again · 15th time

    Roman Barr↗

    3 Apr 2026 · Linda Lee · Coventry

    Identical hazardConfidence 0.95 · higha different coroner
    “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 ↗

    Repeated from the earlier report:ambulancetimeshospitalsresponse

    The most recent report. A response may not be due or published yet.

  17. All reports to NHS England

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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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