Ambulance handover delays due to bed shortages
Welsh Ambulance Service NHS Trust received 10 coroners' reports about this hazard between 26 Aug 2016 and 22 Oct 2024.
They came from 6 different coroners in 5 coroner areas. A similar concern was raised again 9 times after the first warning.
A published response was found for 5 of the 9 earlier reports, stating 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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”
Original on judiciary.uk ↗ Welsh Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Web search (Tavily): No evidence found either way
Annual Report and Accounts 2023/24 ↗- 9 months later
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Original on judiciary.uk ↗ Welsh Ambulance Service NHS Trust responded.Response (PDF) ↗
- 1 year 1 month laterIdentical hazardConfidence 0.90 · higha different coroner
“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 this Court on several occasions”
Original on judiciary.uk ↗ No published response from Welsh Ambulance Service NHS Trust was found for this report.
- 1 month laterIdentical hazardConfidence 0.93 · high
“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”
Original on judiciary.uk ↗ No published response from Welsh Ambulance Service NHS Trust was found for this report.
- 1 month later
“The target turnaround time for ambulances at A&E is wildly unrealistic.”
Original on judiciary.uk ↗ Welsh Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“WAST has reported that at times of increased demand, capacity to undertake welfare calls is reduced and it is currently considering options to increase capacity on its clinical support desk which provides support and advice over the telephone, as well as opportunities for third sector organisations and other agencies (e.g. Police, Fire and Rescue Services) to support the delivery of welfare checks, particularly for patients who have experienced a delayed response.”
Stated timescale: end of this month
Web search (Tavily): No evidence found either way
Medical-Legal Partnerships as Tools to Reduce Child Welfare ... ↗ - 6 months laterIdentical hazardConfidence 0.90 · high
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Original on judiciary.uk ↗ No published response from Welsh Ambulance Service NHS Trust was found for this report.
- 3 years 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“There were no available ambulance resources to convey [the deceased] from Ysbyty Gwynedd to Ysbyty Glan Clwyd.”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulanceresources
Welsh Ambulance Service NHS Trust responded, stating 3 specific actions.Response (PDF) ↗
“The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers.”
Stated timescale: Quarter 4 of this financial year
Web search (Tavily): No evidence found either way
Publications - Welsh Ambulance Services University NHS Trust ↗“The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines.”
Stated timescale: 22 November 2022
Web search (Tavily): No evidence found either way
how our service is changing - Welsh Ambulance Services University NHS Trust ↗1 more stated action in the Promises tab.
- 8 months later
“ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.”
Original on judiciary.uk ↗ No published response from Welsh Ambulance Service NHS Trust was found for this report.
- 5 months laterIdentical hazardConfidence 0.92 · higha different coroner
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Original on judiciary.uk ↗ Repeated from the earlier report:delayspatients
Welsh Ambulance Service NHS Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
Web search (Tavily): No evidence found either way
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
Stated timescale: January 2024
Web search (Tavily): No evidence found either way
Annual Report and Accounts 2023/24 ↗ - 11 months laterIdentical hazardConfidence 0.92 · higha different coroner
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulanceswaitingpatientscalls
Welsh Ambulance Service NHS Trust responded.Response (PDF) ↗
- All reports to Welsh Ambulance Service NHS 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.
2016 → 2018Ester Wood1 year 9 months after Pamela Conway · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight prolonged ambulance delays due to poor patient flow and limited resource availability, which keep ambulances tied up and endanger patients.
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”
Original on judiciary.uk ↗ Ester Wood · 6 Jun 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 this Court on several occasions”
Original on judiciary.uk ↗ 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”
2017 → 2018Margaret Evans1 year 1 month after Lilly Baxandall · same coronerIdentical hazardConfidence 0.93 · high
Identical hazardConfidence 0.93 · highBoth reports describe prolonged ambulance waits due to delayed handovers and limited bed availability, tying patient flow problems to resource unavailability.
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”
Original on judiciary.uk ↗ Margaret Evans · 26 Jun 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”
Original on judiciary.uk ↗ 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”
2016 → 2018Margaret Evans1 year 10 months after Pamela Conway · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that ongoing patient flow problems cause delays in the Emergency Department, leading to ambulance back‑ups and unavailable resources.
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”
Original on judiciary.uk ↗ Margaret Evans · 26 Jun 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.”
Original on judiciary.uk ↗ 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”
2018 → 2019Madeline Staples8 months after Margaret Evans · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight ambulance delays caused by prolonged patient handover at emergency departments, which ties up ambulance resources and puts patients at risk.
Margaret Evans · 26 Jun 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.”
Original on judiciary.uk ↗ 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”
Original on judiciary.uk ↗ 2019 → 2022Glenys Roberts3 years 8 months after Madeline Staples · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance availability caused by delays elsewhere in the health system.
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”
Original on judiciary.uk ↗ Glenys Roberts · 24 Oct 2022
“There were no available ambulance resources to convey [the deceased] from Ysbyty Gwynedd to Ysbyty Glan Clwyd.”
Original on judiciary.uk ↗ 2017 → 2023Lynda Blackmore6 years 6 months after Lilly Baxandall · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports describe handover delays in emergency departments that prevent ambulances from being freed up 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”
Original on judiciary.uk ↗ Lynda Blackmore · 15 Nov 2023
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Original on judiciary.uk ↗ 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”
2022 → 2023Lynda Blackmore1 year 1 month after Glenys Roberts · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with ambulance handover processes that affect service availability and timely patient transport. The earlier report notes the lack of a formal handover plan, while the later report observes that existing handover delays are worsening response times.
Glenys Roberts · 24 Oct 2022
“Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow”
Original on judiciary.uk ↗ Lynda Blackmore · 15 Nov 2023
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU.”
2019 → 2024Peter Parker5 years 8 months after Madeline Staples · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports describe delays caused by ambulances waiting at emergency departments to hand over patients, which makes those ambulances unavailable for other calls.
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”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Original on judiciary.uk ↗ 2023 → 2024Peter Parker1 year 4 months after Jean Frickel · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports describe delays in ambulance availability caused by difficulties offloading patients at hospital emergency departments.
Jean Frickel · 21 Jun 2023
“ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance's duty of care, and therefore not responding to emergency calls as is their purpose.”
Original on judiciary.uk ↗ 2017 → 2024Peter Parker7 years 5 months after Lilly Baxandall · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe ambulances being delayed while waiting to hand over patients at emergency departments, making the vehicles unavailable for other emergency 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”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Original on judiciary.uk ↗ 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”
2016 → 2024Peter Parker8 years 2 months after Pamela Conway · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports describe ambulance delays caused by patients not being transferred promptly at hospital emergency departments, which ties up ambulance resources and prevents them from responding to 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”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Original on judiciary.uk ↗ 2023 → 2024Peter Parker11 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify ambulance handover delays at emergency departments as causing ambulances to be unavailable for new emergency calls, thereby increasing response times and risking patient safety.
Lynda Blackmore · 15 Nov 2023
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
2018 → 2024Peter Parker6 years 3 months after Richard Barrett · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight delays caused by ambulances being held up at hospitals, preventing them from responding to new calls. The earlier report cites unrealistic turnaround targets leading to long waits, while the later report describes actual waits of 11‑12 hours at Emergency Departments.
Richard Barrett · 30 Jul 2018
“The target turnaround time for ambulances at A&E is wildly unrealistic.”
Original on judiciary.uk ↗ Peter Parker · 22 Oct 2024
“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients,”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action · timescale: 2016-05-05
“we have made progress against key actions which are all identified in the attached action plan”
What happened next: No evidence found either way
The Welsh Ambulance Service NHS Trust's 2023/24 Annual Report outlines its performance and governance frameworks but does not reference a 2016-05-05 promised action plan or specific progress against it.
“Part 1: Performance Report which details how the Trust performed in the year and how we adapted and responded to the system pressures currently impacting our patients and our people.”
“Governance: The Trust has strengthened governance arrangements, although performance in key areas is not improving as”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No published response from Welsh Ambulance Service NHS Trust was found for this report.
No published response from Welsh Ambulance Service NHS Trust was found for this report.
Stated action · timescale: end of this month
“WAST has reported that at times of increased demand, capacity to undertake welfare calls is reduced and it is currently considering options to increase capacity on its clinical support desk which provides support and advice over the telephone, as well as opportunities for third sector organisations and other agencies (e.g. Police, Fire and Rescue Services) to support the delivery of welfare checks, particularly for patients who have experienced a delayed response.”
What happened next: No evidence found either way
The organisation did not state a specific completion date for the promised capacity increase.
“The child welfare system can have devastating short- and long-term impacts on children and families. Families experiencing poverty should be met with sup-port rather than pushed into this potentially harmful system. Yet, when families with low incomes and Black families come into contact with health care pro-viders, they are disproportionately funneled into the child welfare system due to existing”
No evidence found does not mean the action did not happen.
No published response from Welsh Ambulance Service NHS Trust was found for this report.
Stated action · timescale: Quarter 4 of this financial year
“The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers.”
What happened next: No evidence found either way
The Welsh Ambulance Service NHS Trust references collaboration with BCU Health Board and NCCU to develop an action plan for improving transfer resources, with a target timeframe of Quarter 4 of the current financial year.
“Integrated Medium Term Plan 2026-2029 Summary”
No evidence found does not mean the action did not happen.
Stated action · timescale: 22 November 2022
“The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines.”
What happened next: No evidence found either way
The Welsh Ambulance Service has updated its patient categorisation system and published a five-year strategy, but no source confirms the development of a bypass protocol for vascular services as described.
“The Welsh Ambulance Service has changed the way it deals with 999 calls. New Orange, Yellow and Green categories replaced the former Amber and Green categories in December 2025. Together with the Purple and Red categories introduced in July 2025 for life-threatening calls, there are now five categories of calls, all designed to ensure patients get the right care for their needs.”
“The primary remit for NHS ambulance services will always be to provide emergency response to those who have life-threatening health needs, and to major incidents as Category 1 civil contingencies responders.”
“Providers covering the Aneurin Bevan University Health Board area: Ambulance Providers: - 121 Medical Services - contact 07855 049647 or 07538 813731 - All Wales Ambulance Service Ltd - contact 01639 830253 - Cartello Ambulance Service - contact 08454 599968”
No evidence found does not mean the action did not happen.
Stated action · timescale: December 2022
“The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU.”
What happened next: No evidence found either way
The Welsh Ambulance Service NHS Trust has not confirmed that the Handover Improvement Plan was implemented by December 2022.
“Healthcare Inspectorate Wales (HIW) has assessed the progress made by Welsh Ambulance Services University NHS Trust (WAST) since reviews published in 2020 and 2021. Those reviews considered the management of patients by emergency call centres and the safety, dignity and experience of patients affected by delayed ambulance handovers.”
No evidence found does not mean the action did not happen.
No published response from Welsh Ambulance Service NHS Trust was found for this report.
Stated action
“We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
What happened next: No evidence found either way
The organisation's statement about producing guidelines for fever in under 5s, sepsis, and sore throat is not supported by any source evidence.
No evidence found does not mean the action did not happen.
Stated action · timescale: January 2024
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
What happened next: No evidence found either way
The Welsh Ambulance Service NHS Trust outlined plans to implement measures in January 2024 to reduce patient conveyances to The Grange Hospital through alternative admissions and a new temporary facility. No source confirms these actions were completed or operational by January 2024.
“It will provide the reader with detail on the Trust's performance and how we responded to changing demands and challenges in 2023/24.”
“Summary ............................................................................................................................ 5 Background ........................................................................................................................ 5 999 Emergency Medical Services ...................................................................................... 7 Remote”
“Document Title: Planning to Safely Reduce Avoidable Conveyance Publishing approval number: Version number: 01 First published: 22 July 2019 Updated: Prepared by: [name redacted]: OFFICIAL This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact the Central Ambulance Team”
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 Welsh Ambulance Service NHS 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 |
|---|---|---|---|---|
| 2016 → 2018 | 0.77 | 0.04 | Identical · 0.90 | different |
| 2017 → 2018 | 0.75 | 0.07 | Identical · 0.93 | same |
| 2016 → 2018 | 0.68 | 0.29 | Identical · 0.90 | same |
| 2018 → 2019 | 0.75 | 0.07 | Identical · 0.90 | same |
| 2019 → 2022 | 0.71 | 0.15 | Closely related · 0.90 | different |
| 2017 → 2023 | 0.81 | 0.15 | Identical · 0.92 | different |
| 2022 → 2023 | 0.73 | 0.12 | Closely related · 0.90 | different |
| 2019 → 2024 | 0.80 | 0.13 | Identical · 0.92 | different |
| 2023 → 2024 | 0.77 | 0.10 | Identical · 0.92 | different |
| 2017 → 2024 | 0.80 | 0.12 | Identical · 0.90 | different |
| 2016 → 2024 | 0.76 | 0.12 | Closely related · 0.90 | different |
| 2023 → 2024 | 0.79 | 0.05 | Identical · 0.90 | different |
| 2018 → 2024 | 0.77 | 0.06 | Closely related · 0.80 | 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.