Ambulance delays leading to resource unavailability

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2014 → 2016Pamela Conway2 years 7 months after Frederick Pring · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports describe unacceptable delays where patients wait in ambulances because emergency department handover or flow processes are inadequate, tying up ambulance resources. The later report notes that the problem persists despite earlier changes.

  Frederick Pring · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues”

  Check it in the source

  Stated action in the response to the earlier report

  “incidents. WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and lower acuity calls”

  Earlier report in the app · Later report in the app

• 2014 → 2017Lilly Baxandall3 years 4 months after Frederick Pring · same coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight that poor handover practices in the Emergency Department cause unacceptable delays for patients waiting in ambulances, making ambulance resources unavailable for other calls.

  Frederick Pring · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2017Lilly Baxandall9 months after Pamela Conway · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight unacceptable delays where patients wait in ambulances because emergency department flow problems make ambulance resources unavailable for other calls.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues”

  Check it in the source

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2016 → 2017Daphne Williams9 months after Pamela Conway · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ongoing delays in patient flow causing ambulance backlogs and emergency department congestion. The later report reiterates the same specific hazard of ambulance delays and resource availability despite prior warnings.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances”

  Check it in the source

  Daphne Williams · 25 May 2017

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2016 → 2017Catherine Roberts10 months after Pamela Conway · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing patient flow problems in the Emergency Department that cause delays and put patients at risk. The earlier report focuses on ambulance back‑up due to ED delays, while the later report stresses continued admission/resource availability issues despite prior warnings.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues”

  Check it in the source

  Catherine Roberts · 7 Jul 2017

  “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2017 → 2018Gladys Williams1 year 4 months after Daphne Williams · same coronerIdentical hazardConfidence 0.96 · high

  Identical hazardConfidence 0.96 · high

  Both reports highlight ongoing ambulance delays, ED admission difficulties, resource availability, and patient flow problems described as multifactorial.

  Daphne Williams · 25 May 2017

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.”

  Check it in the source

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”

  Earlier report in the app · Later report in the app

• 2016 → 2018Gladys Williams2 years after Pamela Conway · same coronerClosely relatedConfidence 0.93 · high

  Closely relatedConfidence 0.93 · high

  Both reports highlight ongoing delays in patient flow causing ambulance queues and ED congestion.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2017 → 2018Gladys Williams1 year 2 months after Catherine Roberts · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing problems with emergency department admission, resource availability, and patient flow that put patients at risk. The later report adds ambulance delays as an additional factor but concerns the same core issue of patient flow and resource constraints.

  Catherine Roberts · 7 Jul 2017

  “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.”

  Check it in the source

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2014 → 2018Gladys Williams4 years 8 months after Frederick Pring · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ambulance handover delays at the emergency department leading to prolonged waits and reduced resource availability. The later report notes these problems persist despite prior interventions.

  Frederick Pring · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”

  Check it in the source

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems”

  Check it in the source

  Stated action in the response to the earlier report

  “incidents. WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and lower acuity calls”

  Earlier report in the app · Later report in the app

• 2017 → 2018Gladys Williams1 year 4 months after Lilly Baxandall · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing ambulance delays affecting patient handover and resource availability.

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”

  Earlier report in the app · Later report in the app

• 2017 → 2019Madeline Staples1 year 9 months after Lilly Baxandall · same coronerIdentical hazardConfidence 0.98 · high

  Identical hazardConfidence 0.98 · high

  Both reports cite the exact same problem: unacceptable delays with patients waiting in ambulances, causing ambulance resources to be unavailable for other calls.

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Madeline Staples · 11 Feb 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”

  Earlier report in the app · Later report in the app

• 2014 → 2019Madeline Staples5 years 1 month after Frederick Pring · same coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports describe unacceptable delays in patient handover at the Emergency Department leading to prolonged ambulance waits and reduced availability for other calls.

  Frederick Pring · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Madeline Staples · 11 Feb 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2019Madeline Staples2 years 6 months after Pamela Conway · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight unacceptable delays causing patients to wait in ambulances, making ambulance resources unavailable for other calls.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Madeline Staples · 11 Feb 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Stated action in the response to the earlier report

  “has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”

  Earlier report in the app · Later report in the app

• 2019 → 2019Peter Connelly9 months after Madeline Staples · same coronerIdentical hazardConfidence 0.96 · high

  Identical hazardConfidence 0.96 · high

  Both reports describe the same problem of unacceptable delays when patients wait in ambulances outside emergency departments, tying up ambulance resources.

  Madeline Staples · 11 Feb 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Peter Connelly · 7 Nov 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2019Peter Connelly2 years 6 months after Lilly Baxandall · same coronerIdentical hazardConfidence 0.96 · high

  Identical hazardConfidence 0.96 · high

  Both reports cite the same specific problem: unacceptable delays with patients waiting in ambulances due to handover issues at the emergency department, which ties up ambulance resources.

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Peter Connelly · 7 Nov 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”

  Earlier report in the app · Later report in the app

• 2014 → 2019Peter Connelly5 years 10 months after Frederick Pring · same coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight unacceptable delays in patient handover at the Emergency Department causing patients to wait in ambulances and tying up ambulance resources.

  Frederick Pring · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Peter Connelly · 7 Nov 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2019Peter Connelly3 years 2 months after Pamela Conway · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight unacceptable delays where patients wait in ambulances, making ambulance resources unavailable for other calls. The underlying issue is the same patient flow problem causing these delays.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.”

  Check it in the source

  Peter Connelly · 7 Nov 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2017 → 2019Peter Connelly2 years 5 months after Daphne Williams · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ambulance delays caused by emergency department handover issues that render ambulances unavailable for other calls.

  Daphne Williams · 25 May 2017

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.”

  Check it in the source

  Peter Connelly · 7 Nov 2019

  “Following an inquest which concluded in January 2014 | issued a regulation 28 report in which | expressed concerns regarding the handover of patients at an emergency department which resulted in”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”

  Earlier report in the app · Later report in the app

• 2017 → 2023David Strachan5 years 9 months after Lilly Baxandall · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe ambulance handover delays that keep patients waiting in ambulances and tie up ambulance resources. The later report notes the same handover problem persisting across all health board sites.

  Lilly Baxandall · 17 May 2017

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  David Strachan · 20 Feb 2023

  “he causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2023Leonard Harmsworth6 years 10 months after Pamela Conway · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight prolonged ambulance waits that tie up resources and increase mortality risk.

  Pamela Conway · 26 Aug 2016

  “That notwithstanding changes which have been made by both BCuHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.”

  Check it in the source

  Leonard Harmsworth · 20 Jun 2023

  “Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2016 → 2023Jean Frickel6 years 10 months after Pamela Conway · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ambulance delays caused by patients being unable to move through the hospital system, specifically due to patient flow and discharge bottlenecks.

  Pamela Conway · 26 Aug 2016

  “there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Jean Frickel · 21 Jun 2023

  “It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department”

  Check it in the source

  Stated action in the response to the earlier report

  “we have made progress against key actions which are all identified in the attached action plan”

  Earlier report in the app · Later report in the app

• 2017 → 2023Mary Jones6 years 1 month after Daphne Williams · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing ambulance delays affecting patient flow into emergency departments.

  Daphne Williams · 25 May 2017

  “ambulance delays/admission to ED/availability of resources/patient flow”

  Check it in the source

  Mary Jones · 10 Jul 2023

  “unacceptably lengthy delays remain such as in the case of [the deceased]”

  Check it in the source

  Stated action in the response to the earlier report

  “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”

  Earlier report in the app · Later report in the app

• 2017 → 2023Mary Jones6 years 2 months after Lilly Baxandall · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in patient flow that impede timely handover or admission of patients. The earlier report cites bed availability and process issues, while the later report adds social care deficiencies as a contributing factor.

  Lilly Baxandall · 17 May 2017

  “substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”

  Check it in the source

  Mary Jones · 10 Jul 2023

  “I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2018 → 2023Mary Jones4 years 10 months after Gladys Williams · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing ambulance delays that impede timely transfer of patients to emergency departments.

  Gladys Williams · 10 Sept 2018

  “The issues of ambulance delays/admission to ED/availability of resources/patient flow”

  Check it in the source

  Mary Jones · 10 Jul 2023

  “unacceptably lengthy delays remain such as in the case of [the deceased]”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2019 → 2023Mary Jones3 years 8 months after Peter Connelly · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ongoing excessive delays in ambulance hand‑over at emergency departments, leading to patients waiting in ambulances and reduced availability of ambulance resources.

  Peter Connelly · 7 Nov 2019

  “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Mary Jones · 10 Jul 2023

  “unacceptably lengthy delays remain such as in the case of [the deceased].”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2023Mary Jones6 years 10 months after Pamela Conway · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight ongoing patient flow problems that cause ambulance delays and prolonged waits in emergency departments. The earlier report focuses on internal hospital flow issues, while the later report attributes the flow deficit to social care deficiencies.

  Pamela Conway · 26 Aug 2016

  “That notwithstanding changes which have been made by both BCuHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Check it in the source

  Mary Jones · 10 Jul 2023

  “Evidence was heard at the Inquest that the initial delays experienced by [the deceased] whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty.”

  Check it in the source

  Stated action in the response to the earlier report

  “has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”

  Earlier report in the app · Later report in the app