Delayed ambulance response to patient deterioration
East of England Ambulance Service received 2 coroners' reports about this hazard between 29 Mar 2018 and 26 Aug 2022.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 8 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them.”
Original on judiciary.uk ↗ East of England Ambulance Service responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to the meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”
Stated timescale: March 2017
“We are planning to arrange a further briefing for HM coroners in the coming months”
Stated timescale: coming months
4 more stated actions in the Promises tab.
- 4 years 5 months laterIdentical hazardConfidence 0.90 · higha different coroner
“2. There were no emergency ambulances available to assign to this call due to high call demand.”
Original on judiciary.uk ↗ Repeated from the earlier report:availabledemand
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 ↗ - 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.
2018 → 2022Christina Ruse4 years 5 months after Matthew Faulkner · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe a situation where demand for ambulance services exceeds available resources, leading to dangerous delays in patient care.
Matthew Faulkner · 29 Mar 2018
“(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them.”
Original on judiciary.uk ↗ Christina Ruse · 26 Aug 2022
“2. 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
“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to the meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”
Stated action · timescale: March 2017
“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to the meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”
Stated action · timescale: coming months
“We are planning to arrange a further briefing for HM coroners in the coming months”
Stated action · timescale: December 2017
“The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter”
Stated action · timescale: January 2018
“Following the risk summit that took place in January 2018, an independent harm review was commissioned by NHS Improvement”
Stated action · timescale: December 2017
“The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter”
Stated action · timescale: December 2017
“The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter”
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.
- 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 |
|---|---|---|---|---|
| 2018 → 2022 | 0.66 | 0.03 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for East of England Ambulance Service
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.