Insufficient ambulance availability leading to delayed emergency response
East of England Ambulance Service received 6 coroners' reports about this hazard between 9 Jan 2014 and 15 Jan 2024.
They came from 6 different coroners in 4 coroner areas. A similar concern was raised again 5 times after the first warning.
A published response was found for 5 of the 5 earlier reports, stating 8 specific actions.
The story, report by report
Spacing grows with the time between reports.
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
Stated timescale: 2013
Web search (Tavily): No evidence found either way
- 2 years 10 months later
“heard evidence that this was not an unusual amount of outstanding calls or an unusual level of waiting time. This was the position on the 26”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
Web search (Tavily): No evidence found either way
East of England Ambulance Service Archives - Emergency Services Times ↗ - 2 years 6 months laterClosely relatedConfidence 0.85 · higha different coroner
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls”
Web search (Tavily): No evidence found either way
2026/27 ambulance emergency and urgent care service ... ↗ - 3 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
Web search (Tavily): No evidence found either way
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
Web search (Tavily): No evidence found either way
East of England Ambulance to take fewer patients to hospital ↗ - 0 months laterClosely relatedConfidence 0.90 · higha different coroner
“There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
Web search (Tavily): No evidence found either way
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
Web search (Tavily): No evidence found either way
East of England Ambulance to take fewer patients to hospital ↗ - 1 year 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“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 ↗ East of England Ambulance Service responded, stating 1 specific action.Response (PDF) ↗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 ↗ - All reports to East of England Ambulance Service
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2016 → 2019Christopher Williams2 years 6 months after Brian Mills · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that excessive delays in ambulance response—whether due to high outstanding calls or prolonged arrival times—pose a risk to patient safety.
Brian Mills · 17 Nov 2016
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
Original on judiciary.uk ↗ Christopher Williams · 31 May 2019
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
2014 → 2022Christina Ruse8 years 8 months after Albert James Hand · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that insufficient ambulance availability leads to excessively long response times, putting patients at risk. The earlier case involved a head‑injury patient waiting over 1.5 hours; the later case involved a delayed ambulance due to high demand and no available units.
Albert James Hand · 9 Jan 2014
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
Original on judiciary.uk ↗ Christina Ruse · 26 Aug 2022
“There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
2016 → 2022Christina Ruse5 years 9 months after Brian Mills · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that excessive call demand leads to insufficient ambulance availability and dangerous delays in patient care. The core issue is the inability to meet response targets due to high volumes of outstanding calls.
Brian Mills · 17 Nov 2016
“heard evidence that this was not an unusual amount of outstanding calls or an unusual level of waiting time. This was the position on the 26”
Original on judiciary.uk ↗ Christina Ruse · 26 Aug 2022
“There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
2014 → 2022Barbara Hollis8 years 8 months after Albert James Hand · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance resources causing dangerous delays in patient transport. The earlier case concerns head‑injury patients waiting over 1.5 hours, while the later case describes no ambulances available for a 999 call due to high demand.
Albert James Hand · 9 Jan 2014
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
Original on judiciary.uk ↗ Barbara Hollis · 26 Aug 2022
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
2016 → 2022Barbara Hollis5 years 9 months after Brian Mills · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that excessive demand on the ambulance service leads to insufficient available resources and dangerous delays in responding to emergencies.
Brian Mills · 17 Nov 2016
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
Original on judiciary.uk ↗ Barbara Hollis · 26 Aug 2022
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
2019 → 2022Christina Ruse3 years 3 months after Christopher Williams · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that ambulance response times were excessively long, exceeding the service's targets. The underlying issue is insufficient ambulance availability leading to dangerous delays in patient care.
Christopher Williams · 31 May 2019
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Original on judiciary.uk ↗ Christina Ruse · 26 Aug 2022
“There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ 2022 → 2024Dennis King1 year 5 months after Barbara Hollis · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance availability leading to dangerous delays in emergency response. The earlier report cites no ambulances for an initial 999 call due to high demand, while the later report stresses untimely ambulance transfers for urgent hospital transfers and 999/111 calls.
Barbara Hollis · 26 Aug 2022
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Original on judiciary.uk ↗ Dennis King · 15 Jan 2024
“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 ↗ Stated action in the response to the earlier report
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
2016 → 2024Dennis King7 years 2 months after Brian Mills · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance availability leading to dangerous delays in emergency care.
Brian Mills · 17 Nov 2016
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
Original on judiciary.uk ↗ Dennis King · 15 Jan 2024
“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 ↗ Stated action in the response to the earlier report
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
2022 → 2024Dennis King1 year 5 months after Christina Ruse · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight insufficient ambulance availability leading to dangerous delays in patient care. The earlier case concerns lack of ambulances for emergency calls, while the later case focuses on delays in inter‑hospital transfers and 999/111 responses.
Christina Ruse · 26 Aug 2022
“There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ Dennis King · 15 Jan 2024
“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 ↗ Stated action in the response to the earlier report
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
Stated action · timescale: 2013
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
What happened next: No evidence found either way
The East of England Ambulance Service's 2025-2026 Annual Quality Account does not mention a Clinical Capacity Review or funding requirements from 2013.
No evidence found does not mean the action did not happen.
Stated action
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
What happened next: No evidence found either way
The East of England Ambulance Service is working with St John Ambulance on a co-responding pilot in Norfolk to support community patient care.
“A new co-responding pilot which will see volunteers from St John Ambulance respond to 999 calls has been launched in Norfolk. The post [Ambulance service partners with St John Ambulance to launch co-responding pilot](https://emergencyservicestimes.com/2026/05/05/ambulance”
No evidence found does not mean the action did not happen.
Stated action
“the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls”
What happened next: No evidence found either way
The East of England Ambulance Service has not published any information confirming or denying the drafting of a Proposal for Change to identify a neurological deficit pathway for triage of 999 calls.
“6.4 Emergency Preparedness, Resilience, and Response (EPRR) 23”
“This document has been approved by the Trust Board and is an accurate account of the level of quality of service provided to patients.”
No evidence found does not mean the action did not happen.
Stated action
“The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
What happened next: No evidence found either way
The Trust states it is working with HSIB to escalate concerns but does not specify any completed action or timeline.
No evidence found does not mean the action did not happen.
Stated action
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
What happened next: No evidence found either way
The East of England Ambulance Service is developing a new approach to ambulance transfers and early notification, aiming to improve response times and ensure patients receive appropriate care closer to home.
“The trust's Patient Plan included that hospitals would no longer be the default destination for patients if it was safe for them to instead receive care closer to home.”
No evidence found does not mean the action did not happen.
Stated action
“The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
What happened next: No evidence found either way
The Trust states it is working with HSIB to escalate concerns but does not specify any completed action or timeline.
No evidence found does not mean the action did not happen.
Stated action
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
What happened next: No evidence found either way
The East of England Ambulance Service is developing a new approach to ambulance transfers and early notification, aiming to improve response times and ensure patients receive appropriate care closer to home.
“The trust's Patient Plan included that hospitals would no longer be the default destination for patients if it was safe for them to instead receive care closer to home.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2023/24
“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”
What happened next: No evidence found either way
NHS England has not provided a specific timeline for addressing ambulance response pressures beyond its general focus on improving performance during 2023/24.
“Escambia County Emergency Medical Services](/story/news/local/escambia-county/2024/02/06/escambia-ems-leaders-vote-no-confidence-in-chief-david-torsell/72480321007/) is making some changes to improve patient safety including purchasing nearly $2 million dollars in new equipment and approving new agreements with local healthcare”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to East of England Ambulance Service at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2019 | 0.63 | 0.05 | Closely related · 0.85 | different |
| 2014 → 2022 | 0.71 | 0.08 | Closely related · 0.90 | different |
| 2016 → 2022 | 0.69 | 0.04 | Closely related · 0.90 | different |
| 2014 → 2022 | 0.65 | 0.09 | Closely related · 0.90 | different |
| 2016 → 2022 | 0.67 | 0.06 | Closely related · 0.85 | different |
| 2019 → 2022 | 0.79 | 0.15 | Closely related · 0.80 | different |
| 2022 → 2024 | 0.70 | 0.12 | Closely related · 0.90 | different |
| 2016 → 2024 | 0.65 | 0.07 | Closely related · 0.90 | different |
| 2022 → 2024 | 0.67 | 0.07 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.