Insufficient ambulance availability leading to delayed response
Department of Health and Social Care received 7 coroners' reports about this hazard between 26 May 2016 and 17 Feb 2025.
They came from 7 different coroners in 7 coroner areas. A similar concern was raised again 6 times after the first warning.
A published response was found for 5 of the 6 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
Web search (Tavily): Evidence found that the action was carried out
East of England Ambulance: Plan to recruit 350 staff ↗- 6 years 8 months laterIdentical hazardConfidence 0.90 · higha different coroner
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Original on judiciary.uk ↗ Repeated from the earlier report:concernedambulanceservice
No published response from Department of Health and Social Care was found for this report.
- 9 months laterIdentical hazardConfidence 0.90 · higha different coroner
“continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulanceresource
Department of Health and Social Care responded.Response (PDF) ↗
- 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“YAS were not resourced to respond to the number of emergency calls”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Delivery plan for recovering urgent and emergency care services ↗ - 5 months laterIdentical hazardConfidence 0.92 · higha different coroner
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Trump Administration Announces $7.2 Million to Expand Ambulance-Based Telemedicine and Upgrade Emergency Communications Across South Dakota | CMS ↗ - 3 months later
Raised again · 5th time
Harry Dunn: Prevention of Future Deaths Report (1)↗
4 Jul 2024 · Anne Pember · Northamptonshire
Identical hazardConfidence 0.90 · higha different coroner“When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust”
Original on judiciary.uk ↗ Repeated from the earlier report:resourcesambulanceService
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Web search (Tavily): No evidence found either way
Independent Investigation of the National Health Service in ... ↗ - 7 months later
Raised again · 6th time
Diana Fairweather-Purkis↗
17 Feb 2025 · Paul Appleton · Teesside and Hartlepool
Identical hazardConfidence 0.90 · higha different coroner“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗ Repeated from the earlier report:insufficientAmbulanceService
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
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 → 2023Rita Taylor6 years 8 months after Peter Scott · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a lack of sufficient ambulance resources leading to delays in patient care. The core concern is that the ambulance service cannot meet demand because ambulances are unavailable.
Peter Scott · 26 May 2016
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ Rita Taylor · 25 Jan 2023
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The need for an urgent review of resources to reduce the risk of future deaths”
2016 → 2023Christopher Hart7 years 5 months after Peter Scott · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight insufficient ambulance resources leading to delays and risk of death.
Peter Scott · 26 May 2016
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ Christopher Hart · 9 Nov 2023
“continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life”
Original on judiciary.uk ↗ 2023 → 2023Christopher Hart9 months after Rita Taylor · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight insufficient ambulance resources causing dangerous delays in patient care. They describe the same mechanism—lack of available ambulances leading to postponed treatment and risk of death.
Rita Taylor · 25 Jan 2023
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Original on judiciary.uk ↗ Christopher Hart · 9 Nov 2023
“I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life.”
Original on judiciary.uk ↗ 2023 → 2023David Briggs10 months after Rita Taylor · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of sufficient ambulance resources leading to delayed responses and potential harm. The earlier case concerns Milton Keynes while the later case involves Yorkshire Ambulance Service, differing in location and service details.
Rita Taylor · 25 Jan 2023
“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
Original on judiciary.uk ↗ David Briggs · 1 Dec 2023
“YAS were not resourced to respond to the number of emergency calls”
Original on judiciary.uk ↗ 2016 → 2023David Briggs7 years 6 months after Peter Scott · different coronerIdentical hazardConfidence 0.85 · high
Identical hazardConfidence 0.85 · highBoth reports highlight insufficient ambulance resources leading to delays in responding to emergency calls.
Peter Scott · 26 May 2016
“I remain very concerned about resource issues for this ambulance service.”
Original on judiciary.uk ↗ David Briggs · 1 Dec 2023
“YAS were not resourced to respond to the number of emergency calls.”
Original on judiciary.uk ↗ 2023 → 2024Jade Griffiths-Jones1 year 3 months after Rita Taylor · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight a shortage of ambulance resources leading to delayed response and patient harm. They describe the same core issue of inadequate ambulance availability despite differing contextual details.
Rita Taylor · 25 Jan 2023
“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
Original on judiciary.uk ↗ Jade Griffiths-Jones · 17 Apr 2024
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Original on judiciary.uk ↗ 2023 → 2024Harry Dunn: Prevention of Future Deaths Report (1)1 year 5 months after Rita Taylor · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a lack of available ambulance resources leading to delayed response and potential harm. The core concern is insufficient ambulance capacity to meet demand.
Rita Taylor · 25 Jan 2023
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Original on judiciary.uk ↗ Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024
“When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust”
Original on judiciary.uk ↗ 2023 → 2025Diana Fairweather-Purkis2 years 1 month after Rita Taylor · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight insufficient ambulance service resources leading to delayed patient attendance and potential harm.
Rita Taylor · 25 Jan 2023
“insufficient ambulance service resources to meet the needs of the City of Milton Keynes”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗ 2023 → 2025Diana Fairweather-Purkis1 year 3 months after Christopher Hart · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient ambulance resources causing delays in attending patients within target times. The later report adds handover delays but the core hazard remains the same.
Christopher Hart · 9 Nov 2023
“continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life”
Original on judiciary.uk ↗ Diana Fairweather-Purkis · 17 Feb 2025
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Original on judiciary.uk ↗
Stated action
“In 2015/16, the trust carried out a significant recruitment campaign and educated 350 whole time equivalent frontline posts.”
What happened next: Evidence found that the action was carried out
The trust announced plans to recruit over 350 staff to improve patient care and staff morale, citing £5m of additional investment for new posts.
“The trust's "turnaround plan" lists measures including recruiting more paramedics, tackling sickness and restructuring management.”
“The trust said it planned to recruit 82 specialist paramedics, 149 paramedics, 24 emergency medical technicians and 96 emergency care assistants.”
“The recruitment drive, in addition to reducing staff sickness and its spending on private ambulances, would enable it to provide the equivalent of an extra 25 of its own double-staffed ambulances, available around the clock,”
No published response from Department of Health and Social Care was found for this report.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2023/24
“published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times”
What happened next: No evidence found either way
The Department of Health and Social Care has not yet published the promised 'Delivery plan for recovering urgent and emergency care services' for 2023/24, according to available sources.
“In 2023, the government published a [plan](https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-urgent-and-emergency-care-services-january-2023/) for recovering urgent and emergency care services, which built on two headline targets: reducing average category two ambulance response times to 30 minutes, and improving A&E waiting times.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2023/24
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times.”
What happened next: No evidence found either way
No source confirms that £200 million was allocated to ambulance services in 2023/24 for expansion and response improvements.
“Trump Administration announced $7.2 million in Rural Health Transformation Program (RHTP) funding to modernize emergency medical services (EMS) for South Dakota. This investment will provide first responders with modern telemedicine tools, expanded training, and faster access to patient data, helping them respond to emergencies and better connect rural patients with care across South Dakota.”
“This article considers how to reliably provide emergency medical services (EMS). EMS responses are critical functions of local governments, yet, in rural areas, many are staffed by licensed volunteers. As requests for emergency health services increase and the workforce decreases, transitioning to a paid workforce is critical to maintaining response capacity. This article discusses the need and”
“February 11, 2025 By[[name redacted] R. [name redacted], MS, RN, NREMT-P](https://www.jems.com/author/daniel-r-gerard-ms-rn/) 15 min read ##”
No evidence found does not mean the action did not happen.
Stated action
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
What happened next: No evidence found either way
The Department of Health and Social Care has not announced a specific timeline for completing the promised investigation into NHS performance.
“Independent Investigation of the National Health Service in England The Rt Hon. Professor the Lord Darzi of Denham OM KBE FRS FMedSci HonFREng September 2024 © Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit www.nationalarchives.gov.uk/ doc/open-government-licence/version/3 Where we”
“Independent investigation of NHS performance: terms of reference Published 11 July 2024 ## Applies to England ## Contents”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
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 Department of Health and Social Care 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 → 2023 | 0.75 | 0.23 | Identical · 0.90 | different |
| 2016 → 2023 | 0.81 | 0.22 | Identical · 0.90 | different |
| 2023 → 2023 | 0.79 | 0.18 | Identical · 0.90 | different |
| 2023 → 2023 | 0.80 | 0.21 | Closely related · 0.90 | different |
| 2016 → 2023 | 0.77 | 0.22 | Identical · 0.85 | different |
| 2023 → 2024 | 0.79 | 0.18 | Identical · 0.92 | different |
| 2023 → 2024 | 0.76 | 0.27 | Identical · 0.90 | different |
| 2023 → 2025 | 0.77 | 0.22 | Identical · 0.90 | different |
| 2023 → 2025 | 0.76 | 0.16 | Closely related · 0.90 | 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.