Delayed ambulance response due to missed urgency recognition
North East Ambulance Service NHS Foundation Trust received 3 coroners' reports about this hazard between 23 Mar 2016 and 22 Jan 2024.
They came from 2 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“the reasons for the delay of the ambulance arrival include severe demand and shortages in the division.”
Original on judiciary.uk ↗ North East Ambulance Service NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.”
- 3 years 8 months later
“Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at [the deceased]'s side.”
Original on judiciary.uk ↗ No published response from North East Ambulance Service NHS Foundation Trust was found for this report.
- 4 years 2 months laterClosely relatedConfidence 0.85 · higha different coroner
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Original on judiciary.uk ↗ North East Ambulance Service NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to North East Ambulance Service NHS Foundation Trust
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.
2019 → 2024Donna Smith4 years 2 months after Maureen Wharton · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in recognizing the urgency of a patient's condition, leading to delayed ambulance response. The earlier case involved missed evaluation of information during the call, while the later case concerned inadequate detection of worsening conditions and lack of call escalation.
Maureen Wharton · 6 Dec 2019
“Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at [the deceased]'s side.”
Original on judiciary.uk ↗ Donna Smith · 22 Jan 2024
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Original on judiciary.uk ↗ 2016 → 2024Donna Smith7 years 10 months after Mandeep Singh · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify delays in ambulance response times as a safety concern. The earlier report attributes delays to high demand and staffing shortages, while the later report cites inadequate detection of worsening conditions by call handlers.
Mandeep Singh · 23 Mar 2016
“the reasons for the delay of the ambulance arrival include severe demand and shortages in the division.”
Original on judiciary.uk ↗ Donna Smith · 22 Jan 2024
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Original on judiciary.uk ↗
Stated action
“the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.”
No published response from North East Ambulance Service NHS Foundation Trust was found for this report.
No specific action could be extracted with a verified quote.
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 North East Ambulance Service NHS Foundation Trust 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 |
|---|---|---|---|---|
| 2019 → 2024 | 0.65 | 0.03 | Closely related · 0.85 | different |
| 2016 → 2024 | 0.71 | 0.20 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for North East Ambulance Service NHS Foundation Trust
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.