Delayed ambulance handover at hospitals

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.

• 2015 → 2016Peter Scott1 year after Barbara Patterson · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify delayed patient hand‑over at hospitals as a factor that jeopardises ambulance availability. The earlier report focuses on crew delays during hand‑over, while the later report calls for strategies to improve handover times.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”

  Check it in the source

  Peter Scott · 26 May 2016

  “Consideration should be given to strategies to improve handover times at hospitals.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2015 → 2022Grenville Wait7 years 1 month after Barbara Patterson · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight that ambulance services are failing to meet required response times. The earlier report details a specific breach of an 8‑minute target, while the later report notes ongoing national failures to meet category 2 response targets.

  Barbara Patterson · 21 May 2015

  “The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”

  Check it in the source

  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust's average response”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2017 → 2022Grenville Wait4 years 10 months after Anthony McCormack · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that national ambulance response time targets are not being met. They refer to the same systemic issue of delayed responses despite previous interventions.

  Anthony McCormack · 4 Sept 2017

  “I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources”

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  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally.”

  Check it in the source

  Stated action in the response to the earlier report

  “I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels.”

  Earlier report in the app · Later report in the app

• 2015 → 2022Ronald Hartley7 years 5 months after Elizabeth Leah · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe a prolonged ambulance response time of about six hours due to high demand on the ambulance service. This delay forced families to consider alternative transport for patients needing urgent hospital care.

  Elizabeth Leah · 19 Feb 2015

  “On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive.”

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  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2023Veronica Jenkins9 months after Grenville Wait · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify delayed ambulance response times as a safety concern. The earlier report notes nationwide missed targets, while the later report links delays to staff shortages and hospital handovers.

  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally.”

  Check it in the source

  Veronica Jenkins · 31 Mar 2023

  “a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”

  Check it in the source

  Stated action in the response to the earlier report

  “The NHS will also set out detailed recovery plans in the new year, including plans to improve ambulance response times and improve A&E waiting times.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Michael Bray11 months after Grenville Wait · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance response times for Category 2 calls consistently fail to meet national targets, creating ongoing safety risks.

  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally.”

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  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2023Michael Bray1 year 1 month after John Murphy · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that delays in ambulance response to Category 2 calls pose a risk of further deaths. The underlying cause is insufficient staff and emergency vehicle resources leading to persistent missed response targets.

  John Murphy · 22 Apr 2022

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”

  Check it in the source

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.”

  Check it in the source

  Stated action in the response to the earlier report

  “The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Joan Corcoran1 year after Grenville Wait · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance response times for category 2 calls are consistently failing to meet national targets. They describe the same systemic delay issue without differing in the specific hazard or mechanism.

  Grenville Wait · 24 Jun 2022

  “Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken via its patient safety plan to manage and respond to demands on its service, it is a matter of concern that target response times are still routinely not being met nationally.”

  Check it in the source

  Joan Corcoran · 20 Jun 2023

  “The inquest heard evidence that under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2023Joan Corcoran5 years 9 months after Anthony McCormack · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight failures to meet Department of Health ambulance response time targets. They differ in the specific call categories and metrics cited.

  Anthony McCormack · 4 Sept 2017

  “I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health”

  Check it in the source

  Joan Corcoran · 20 Jun 2023

  “under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2023Joan Corcoran8 years 1 month after Barbara Patterson · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight that ambulance response times exceeded the required targets, indicating a systemic delay in getting ambulances to patients. The earlier report concerns an 8‑minute target breached with a 15‑minute wait, while the later report concerns category‑2 targets (average 18 min, 90 % within 40 min) breached with waits over an hour.

  Barbara Patterson · 21 May 2015

  “The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes”

  Check it in the source

  Joan Corcoran · 20 Jun 2023

  “The inquest heard evidence that under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Thelma Radmore8 months after Derek Shaw · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in ambulance response caused by pressures on healthcare services and resource constraints. The later report adds context about emergency department crowding but the core hazard remains ambulance delay due to system demand.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  Thelma Radmore · 19 Jul 2023

  “The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”

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  Earlier report in the app · Later report in the app

• 2023 → 2023Thelma Radmore6 months after Lyn Brind · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delays in moving patients from ambulances to hospital care caused by insufficient bed capacity due to blocked discharges and high demand.

  Lyn Brind · 18 Jan 2023

  “Evidence was heard that there was a delay in Mrs [name redacted] being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital”

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  Thelma Radmore · 19 Jul 2023

  “The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”

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  Earlier report in the app · Later report in the app

• 2023 → 2023Thelma Radmore6 months after Kyriacos Athanasis · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe delays in ambulance handovers caused by insufficient space in the emergency department due to high demand and poor patient flow.

  Kyriacos Athanasis · 6 Jan 2023

  “(1) Evidence given at the inquest revealed that there was a delay in Mr. [name redacted] being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into.”

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  Thelma Radmore · 19 Jul 2023

  “1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”

  Check it in the source

  Stated action in the response to the earlier report

  “the Integrated Care Board (ICB) responsible for JPUH, Norfolk and Waveney ICB, provided a comprehensive response on 3 February 2023 which included information on the improvements being made locally, and details of a serious incident investigation report following Mr [name redacted]' death.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Lee Dryden1 year 1 month after Ronald Hartley · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in ambulance response caused by systemic pressures on the ambulance service. The earlier case involved a six‑hour wait due to high demand, while the later case involved a two‑hour‑twenty‑six‑minute delay for a category 2 call during peak escalation.

  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”

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  Lee Dryden · 2 Aug 2023

  “2. The Ambulance Service graded [the deceased]'s mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded too within 40 minutes. Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at”

  Check it in the source

  Stated action in the response to the earlier report

  “The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Geoffery Hoad1 year 2 months after Ronald Hartley · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe excessively long waits for an ambulance caused by high demand on the ambulance service. The core concern is that delayed response times put patients at risk.

  Ronald Hartley · 17 Jul 2022

  “they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend”

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  Geoffery Hoad · 13 Sept 2023

  “Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours.”

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  Earlier report in the app · Later report in the app

• 2022 → 2023Geoffery Hoad10 months after Ellen MacFarlane · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight excessively long ambulance response times caused by high demand and insufficient resources such as staffing shortages and vehicle availability.

  Ellen MacFarlane · 4 Nov 2022

  “notwithstanding her age and frailty [the deceased] had to wait over 5 hours for an ambulance. This was due to the demands on the North West Ambulance Service on the day in question.”

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  Geoffery Hoad · 13 Sept 2023

  “Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”

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  Earlier report in the app · Later report in the app

• 2016 → 2023Geoffery Hoad7 years 4 months after Christopher Fields · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight excessively long ambulance response times compared to the target times set by the call‑coding system. The underlying issue is insufficient resources or capacity to meet demand.

  Christopher Fields · 18 May 2016

  “The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”

  Check it in the source

  Geoffery Hoad · 13 Sept 2023

  “The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”

  Check it in the source

  Stated action in the response to the earlier report

  “NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”

  Earlier report in the app · Later report in the app

• 2015 → 2023Geoffery Hoad8 years 7 months after Elizabeth Leah · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight excessively long waits for an ambulance due to insufficient ambulance/resources and high system demand.

  Elizabeth Leah · 19 Feb 2015

  “They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive.”

  Check it in the source

  Geoffery Hoad · 13 Sept 2023

  “The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2023John Winsworth1 year 2 months after Ronald Hartley · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight excessively long waits for an ambulance due to service pressures. The earlier case involved a six‑hour delay while the later case involved a delay of over nineteen hours.

  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”

  Check it in the source

  John Winsworth · 29 Sept 2023

  “The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”

  Check it in the source

  Stated action in the response to the earlier report

  “The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.”

  Earlier report in the app · Later report in the app

• 2015 → 2023Christopher Hart8 years 6 months after Barbara Patterson · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight delays in ambulance response leading to missed treatment opportunities.

  Barbara Patterson · 21 May 2015

  “The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”

  Check it in the source

  Christopher Hart · 9 Nov 2023

  “had an ambulance for [the deceased] arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2016 → 2023Lynda Blackmore7 years 6 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delayed patient handover at hospitals as a factor that increases risk to patients needing emergency care. The earlier report calls for strategies to improve handover times, while the later report observes that such delays are already affecting ambulance response times.

  Peter Scott · 26 May 2016

  “Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2023Lynda Blackmore8 months after Veronica Jenkins · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify handover delays at hospitals as a factor that prolongs ambulance response times and endangers patient safety. The earlier report also cites staff shortages, while the later report focuses solely on handover delays exceeding Welsh targets.

  Veronica Jenkins · 31 Mar 2023

  “This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region.”

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  Lynda Blackmore · 15 Nov 2023

  “As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”

  Check it in the source

  Stated action in the response to the earlier report

  “SECAmb had planned for 2370.1 WTE by 31 March 2023.”

  Earlier report in the app · Later report in the app

• 2016 → 2023Kenneth Heard7 years 6 months after Peter Scott · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify prolonged patient handover at emergency departments as a safety risk causing ambulance delays.

  Peter Scott · 26 May 2016

  “Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Kenneth Heard · 23 Nov 2023

  “The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department.”

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  Earlier report in the app · Later report in the app

• 2022 → 2023David Briggs1 year 1 month after Derek Shaw · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in ambulance response that contributed to preventable deaths. The earlier report cites systemic capacity issues causing delayed attendance, while the later report describes a specific delayed response due to call grading, off‑load bottlenecks and resource shortages.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  David Briggs · 1 Dec 2023

  “The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022.”

  Check it in the source

  Stated action in the response to the earlier report

  “The report raises concerns about ambulance capacity and response times by East of England Ambulance Service NHS Trust (EEAST). In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). I have been informed that the CQC carried out routine engagement with the Trust to review progress against its action plan and to ensure they comply with CQC regulations. More generally, I have been assured that the CQC will continue to have regular”

  Earlier report in the app · Later report in the app

• 2015 → 2023Shaun Parks8 years 7 months after Barbara Patterson · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports identify delays in offloading patients at hospitals as a factor that ties up ambulance resources and prolongs response times. The earlier report notes this as a general issue affecting availability, while the later report links it directly to a 3‑hour‑18‑minute response delay.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”

  Check it in the source

  Shaun Parks · 20 Dec 2023

  “There was a significant delay in offloading patients at hospitals, which tied up resources and meant they were unable to respond to emergency calls.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2023Shaun Parks6 months after Joan Corcoran · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify excessively long ambulance response times as a hazard that likely worsened patient outcomes. The specific concern is that delays beyond target response intervals reduce the chance of timely hospital treatment.

  Joan Corcoran · 20 Jun 2023

  “under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes”

  Check it in the source

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2023Shaun Parks7 years 7 months after Christopher Fields · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight excessively long ambulance response times caused by insufficient resources and staffing levels.

  Christopher Fields · 18 May 2016

  “In the event, the vehicle did not arrive for 2 hours 8 minutes.”

  Check it in the source

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Stated action in the response to the earlier report

  “NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”

  Earlier report in the app · Later report in the app

• 2022 → 2023Shaun Parks1 year 5 months after Ronald Hartley · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that excessive ambulance response times led to avoidable harm or worsened outcomes. The earlier case involved a six‑hour wait prompting family transport, while the later case cites a three‑hour‑eighteen‑minute delay linked to staffing and hospital off‑loading issues.

  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”

  Check it in the source

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2023James Campion1 year 5 months after Ronald Hartley · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe a harmful delay in ambulance response caused by high demand on the ambulance service. The delay prevented timely medical treatment and led to adverse outcomes for the individuals involved.

  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”

  Check it in the source

  James Campion · 20 Dec 2023

  “The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2023James Campion1 year 1 month after Derek Shaw · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify a delay in ambulance response as a contributing factor to a preventable death.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  James Campion · 20 Dec 2023

  “The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2023Shaun Parks7 months after Michael Bray · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that prolonged ambulance response times increase the risk of adverse outcomes. The earlier report concerns persistent Category 2 delays, while the later report cites a specific 3‑hour‑18‑minute delay due to staffing and hospital off‑load issues.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2023James Campion8 years 7 months after Barbara Patterson · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight problems with ambulance dispatch timeliness affecting patient outcomes. The earlier report cites a systemic fault causing ambulances not to be sent close enough, while the later report notes dispatch delays due to high demand preventing timely treatment.

  Barbara Patterson · 21 May 2015

  “The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location”

  Check it in the source

  James Campion · 20 Dec 2023

  “The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Donna Smith8 months after Michael Bray · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that prolonged ambulance response times for Category 2 calls pose a risk of avoidable deaths. They differ in focus: the earlier report stresses persistent systemic delays, while the later report notes a specific breach and inadequate detection of worsening conditions.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Donna Smith · 22 Jan 2024

  “The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.”

  Check it in the source

  Stated action in the response to the earlier report

  “published our Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2022 → 2024Peter Beresford1 year 11 months after John Murphy · same coronerIdentical hazardConfidence 0.98 · high

  Identical hazardConfidence 0.98 · high

  Both reports identify that delays in paramedics attending Category 2 calls persist despite measures, due to residual staff and emergency vehicle shortages. They also note that ambulance resource use is limited by A&E department pressures across the NHS.

  John Murphy · 22 Apr 2022

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”

  Check it in the source

  Peter Beresford · 12 Mar 2024

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”

  Check it in the source

  Stated action in the response to the earlier report

  “The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Peter Beresford10 months after Michael Bray · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that delays in responding to Category 2 ambulance calls remain unresolved and pose a risk of future deaths. The earlier report cites persistent ineffectiveness of actions, while the later points to ongoing staff and vehicle shortages.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Peter Beresford · 12 Mar 2024

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges”

  Check it in the source

  Stated action in the response to the earlier report

  “published our Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2023 → 2024Jean Walker6 months after Geoffery Hoad · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in ambulance response caused by bottlenecks in hospital patient off‑loading or handover processes. The earlier report notes ambulances waiting at hospitals due to high demand, while the later report cites significant off‑loading delays tying up ambulance resources.

  Geoffery Hoad · 13 Sept 2023

  “Evidence was heard as to the very high call demand overnight on 6t h and ih August 2022 and with regard to the number of ambulances waiting at Hospitals in the region to hand over patients”

  Check it in the source

  Jean Walker · 20 Mar 2024

  “There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Jean Walker8 months after Lee Dryden · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delays in hospital patient off‑loading or handover as the cause of ambulance unavailability. The earlier report cites handover delays; the later report cites offloading delays, describing the same operational bottleneck.

  Lee Dryden · 2 Aug 2023

  “significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”

  Check it in the source

  Jean Walker · 20 Mar 2024

  “There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2024Jean Walker7 years 10 months after Christopher Fields · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight unacceptably long delays in ambulance arrival after an emergency call.

  Christopher Fields · 18 May 2016

  “In the event, the vehicle did not arrive for 2 hours 8 minutes.”

  Check it in the source

  Jean Walker · 20 Mar 2024

  “The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”

  Check it in the source

  Stated action in the response to the earlier report

  “NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”

  Earlier report in the app · Later report in the app

• 2022 → 2024Patricia Eyken1 year 4 months after Derek Shaw · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify an ambulance delay as a factor that prevented timely lifesaving treatment and contributed to a death.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased”

  Check it in the source

  Patricia Eyken · 25 Mar 2024

  “[the deceased]'s death followed an ambulance delay, attributable to a systemic failure, which is likely to have contributed to [the deceased]'s death by preventing lifesaving treatment.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2024Jade Griffiths-Jones8 years 11 months after Barbara Patterson · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports describe ambulance crew availability being compromised by delays at hospitals during patient handover, leading to longer response times and risk to life.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”

  Check it in the source

  Jade Griffiths-Jones · 17 Apr 2024

  “availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Jade Griffiths-Jones11 months after Michael Bray · different coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports highlight that ambulance services fail to meet national Category 2 response time targets, creating a risk of preventable deaths.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Jade Griffiths-Jones · 17 Apr 2024

  “could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Jade Griffiths-Jones7 months after Geoffery Hoad · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that the ambulance service could not meet Category 2 response time targets because of high demand and delays at hospital handover.

  Geoffery Hoad · 13 Sept 2023

  “The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.”

  Check it in the source

  Jade Griffiths-Jones · 17 Apr 2024

  “could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2022 → 2024Jade Griffiths-Jones1 year 10 months after Grenville Wait · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance services are failing to meet nationally set response time targets. The underlying issue described is that operational delays (such as hospital handover waits) prevent crews from responding promptly.

  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust's average response”

  Check it in the source

  Jade Griffiths-Jones · 17 Apr 2024

  “West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2024Jade Griffiths-Jones1 year 7 months after Irene Davies · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that ambulance service delays prevented meeting Category 2 response targets. The underlying issue is insufficient ambulance availability/resources leading to distressingly long waits.

  Irene Davies · 14 Sept 2022

  “The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time.”

  Check it in the source

  Jade Griffiths-Jones · 17 Apr 2024

  “could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2024Richard Carpenter1 year 5 months after Derek Shaw · different coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports highlight that delays in ambulance attendance increase the risk of preventable deaths.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  Richard Carpenter · 25 Apr 2024

  “delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Richard Carpenter11 months after Michael Bray · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance response times for Category 2 calls as creating an increased risk of preventable deaths.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Richard Carpenter · 25 Apr 2024

  “delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Richard Carpenter10 months after Joan Corcoran · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ambulance response delays caused by ambulances being held up at hospitals awaiting handover or bed availability. The earlier report focuses on overall system demand and A&E congestion, while the later report emphasizes specific hospital handover delays and bed blocking.

  Joan Corcoran · 20 Jun 2023

  “The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time.”

  Check it in the source

  Richard Carpenter · 25 Apr 2024

  “although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover.”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times”

  Earlier report in the app · Later report in the app

• 2022 → 2024Bobilya Mulonge2 years 1 month after John Murphy · same coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify that delays in paramedics attending Category 2 calls persist because ambulance resources cannot be fully used due to hold-ups in clearing Accident and Emergency departments.

  John Murphy · 22 Apr 2022

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”

  Check it in the source

  Bobilya Mulonge · 8 May 2024

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.”

  Check it in the source

  Stated action in the response to the earlier report

  “The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Bobilya Mulonge1 year after Michael Bray · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify prolonged ambulance response times for Category 2 calls as creating a risk of further deaths.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Bobilya Mulonge · 8 May 2024

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Harry Dunn: Prevention of Future Deaths Report (1)7 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight prolonged ambulance handover delays at emergency departments as a safety concern. They link these delays to increased risk of future deaths.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

  Check it in the source

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Harry Dunn: Prevention of Future Deaths Report (1)8 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays at hospitals as a problem that worsens response times and endangers patients needing emergency care.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Harry Dunn: Prevention of Future Deaths Report (1)11 months after Lee Dryden · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that delays in ambulance handovers at emergency departments reduce ambulance availability and worsen response times. The core concern is the impact of hospital handover bottlenecks on timely ambulance response.

  Lee Dryden · 2 Aug 2023

  “Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”

  Check it in the source

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.”

  Check it in the source

  Stated action in the response to the earlier report

  “Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”

  Earlier report in the app · Later report in the app

• 2016 → 2024Harry Dunn: Prevention of Future Deaths Report (1)8 years 1 month after Peter Scott · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify prolonged ambulance handover delays at hospitals as a safety risk affecting patient outcomes.

  Peter Scott · 26 May 2016

  “Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Susan Dear10 months after Kenneth Heard · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify ambulance handover delays at hospitals as a key factor causing prolonged ambulance response times. The earlier report concerns delays at Treliske and Derriford hospitals in Cornwall, while the later report concerns delays at Royal Berkshire and Wexham Park hospitals in Berkshire.

  Kenneth Heard · 23 Nov 2023

  “The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”

  Check it in the source

  Susan Dear · 20 Sept 2024

  “handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available)”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Kevin Woods10 months after Kenneth Heard · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover delays as the core problem affecting response times and patient safety. They describe how these delays increase risk of harm, though the later report adds detail about concealed spikes and broader system factors.

  Kenneth Heard · 23 Nov 2023

  “Evidence heard at [the deceased]'s Inquest indicates that there is a strong relationship between the hours lost due to handover delays and the response times being delivered by SWAST.”

  Check it in the source

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Kevin Woods11 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays as a factor that worsens response times for patients needing emergency care. They describe how these delays increase mortality risk.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Kevin Woods10 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ongoing delays in ambulance handover to emergency departments as a safety concern. They describe how these delays increase mortality risk and have worsened despite prior improvements.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

  Check it in the source

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Henry Willems1 year 4 months after Joan Corcoran · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify that failing to meet the Department of Health's Category 2 ambulance response time target (18‑minute average, 40‑minute 90th percentile) led to a preventable death. The underlying issue is excessive ambulance delays caused by hospital handover bottlenecks and high demand.

  Joan Corcoran · 20 Jun 2023

  “under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases”

  Check it in the source

  Henry Willems · 21 Oct 2024

  “Mr. [name redacted]' case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90th percentile response time is 40 minutes;”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2024Henry Willems6 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify hospital handover delays as compromising ambulance availability and extending response times. They describe the same mechanism whereby delays at hospitals prevent ambulances from meeting response targets.

  Jade Griffiths-Jones · 17 Apr 2024

  “if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”

  Check it in the source

  Henry Willems · 21 Oct 2024

  “The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.”

  Check it in the source

  Stated action in the response to the earlier report

  “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

  Earlier report in the app · Later report in the app

• 2022 → 2024Simon Boyd2 years 4 months after Grenville Wait · same coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports highlight that national ambulance response time targets are consistently not being met. They refer to the same underlying issue of delayed ambulance arrivals despite established performance standards.

  Grenville Wait · 24 Jun 2022

  “target response times are still routinely not being met nationally”

  Check it in the source

  Simon Boyd · 6 Nov 2024

  “national targets for ambulance response times continue not to be adhered to”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2017 → 2024Simon Boyd7 years 2 months after Anthony McCormack · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that national ambulance response time targets are not being met. They describe systemic failures leading to delayed ambulance arrivals despite set performance standards.

  Anthony McCormack · 4 Sept 2017

  “I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health”

  Check it in the source

  Simon Boyd · 6 Nov 2024

  “The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”

  Check it in the source

  Stated action in the response to the earlier report

  “I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Andrew Lewis1 year 1 month after David Briggs · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight ambulance delays caused by prolonged patient off‑loading or queuing at hospitals, which reduces ambulance availability for emergency calls.

  David Briggs · 1 Dec 2023

  “There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”

  Check it in the source

  Andrew Lewis · 19 Dec 2024

  “I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024).”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Andrew Lewis1 year 3 months after John Winsworth · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance responses far exceeded the required 2‑hour target, indicating systemic delays in emergency medical attendance.

  John Winsworth · 29 Sept 2023

  “The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”

  Check it in the source

  Andrew Lewis · 19 Dec 2024

  “An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2024Andrew Lewis9 months after Jean Walker · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ambulance delays caused by prolonged hospital handover or queuing, which ties up resources and prevents timely responses.

  Jean Walker · 20 Mar 2024

  “The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”

  Check it in the source

  Andrew Lewis · 19 Dec 2024

  “I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024).”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Andrew Lewis1 year 3 months after Geoffery Hoad · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that excessive demand on the ambulance service leads to unacceptably long response times despite categorisation requiring rapid attendance.

  Geoffery Hoad · 13 Sept 2023

  “Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”

  Check it in the source

  Andrew Lewis · 19 Dec 2024

  “An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2023 → 2024Andrew Lewis1 year after Shaun Parks · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight excessively long ambulance response times caused by systemic pressures on ambulance services. The earlier report cites a 3‑hour‑18‑minute delay linked to staffing shortages and hospital offload delays, while the later report describes a ~10‑hour delay associated with sustained high escalation levels and extensive hospital queue hours.

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Andrew Lewis · 19 Dec 2024

  “An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2025Nicola Owens9 years 8 months after Barbara Patterson · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify ambulance crew delays during hospital hand‑over as a cause of reduced ambulance availability.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”

  Check it in the source

  Nicola Owens · 31 Jan 2025

  “This delay being significantly contributed to by the handover delays in hospitals.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Nicola Owens1 year 3 months after Lynda Blackmore · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify handover delays in hospitals as a factor that reduces ambulance availability and slows emergency response. The later report adds that these delays are worsened by discharge backlogs, but the core concern remains handover delays impacting ambulance response.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025Nicola Owens7 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays at hospitals as reducing ambulance availability and increasing risk to patients. The later report adds that discharge backlogs exacerbate the handover problem, but the core hazard remains the same.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2023 → 2025Nicola Owens1 year 2 months after Kenneth Heard · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify ambulance delays caused by prolonged patient handover times at hospitals. The later report adds that handover delays are driven by a backlog of patients awaiting social care, while the earlier report focuses on overall demand and handover process delays.

  Kenneth Heard · 23 Nov 2023

  “The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”

  Check it in the source

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Nicola Owens1 year 2 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight ambulance delays caused by hospital handover problems. The later report adds that handover delays stem from social‑care discharge backlogs.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “During the course of these inquests, the evidence has revealed matters giving rise to concern.”

  Check it in the source

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2025Diana Fairweather-Purkis9 years 9 months after Barbara Patterson · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight that ambulance crews experience excessive delays when trying to hand over patients to hospital staff, which reduces ambulance availability.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”

  Check it in the source

  Diana Fairweather-Purkis · 17 Feb 2025

  “There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Lachlan Campbell (2)10 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify hospital handover delays as the cause of delayed ambulance responses, creating a risk to life.

  Jade Griffiths-Jones · 17 Apr 2024

  “availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Stated action in the response to the earlier report

  “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Lachlan Campbell (2)8 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify ambulance response delays caused by prolonged patient handover times at hospital emergency departments. The core concern is that these handover bottlenecks create a risk of avoidable deaths.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2023 → 2025Lachlan Campbell (2)1 year 3 months after John Seagrove, Pauline Humphris and Patricia Steggles · same coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports identify delays in ambulance response caused by prolonged handover of patients at the hospital emergency department. The core issue is the same bottleneck affecting ambulance availability.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Lachlan Campbell (2)1 year 3 months after Lynda Blackmore · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports identify ambulance handover delays as a factor that prolongs emergency response times and endangers patients. The earlier report concerns Welsh ambulance service handover delays, while the later report focuses on delays at Royal Cornwall Hospital in Cornwall.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Stated action in the response to the earlier report

  “have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”

  Earlier report in the app · Later report in the app

• 2023 → 2025Lachlan Campbell (2)1 year 3 months after Kenneth Heard · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance response delays caused by prolonged patient handover times at the main Cornwall hospitals.

  Kenneth Heard · 23 Nov 2023

  “The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall:”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Lachlan Campbell (2)1 year 7 months after Lee Dryden · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delays in patient handover at hospitals as a cause of prolonged ambulance response times. The specific hazard is the same, though the ambulance trusts and hospital locations differ.

  Lee Dryden · 2 Aug 2023

  “Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”

  Check it in the source

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Stated action in the response to the earlier report

  “Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Andrew Waters9 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight ambulance handover delays at hospitals that tie up resources and increase mortality risk.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2023 → 2025Andrew Waters1 year 5 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify handover delays in hospitals as causing ambulance resources to be tied up, which increases risk to patients needing emergency care.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025Andrew Waters6 months after Kevin Woods · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify handover delays at hospitals as a hazard that increases mortality risk. They link these delays to insufficient social care and patient flow problems.

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”

  Check it in the source

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”

  Earlier report in the app · Later report in the app

• 2015 → 2025Andrew Waters9 years 10 months after Barbara Patterson · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance crews are delayed when handing patients over to hospital staff, tying up ambulance resources. This delay increases risks for patients awaiting emergency care.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”

  Check it in the source

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Bernard Lyon1 year 5 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays as a factor that prolongs response times and ties up ambulances. The core concern is the same: delays in transferring patients from ambulance to emergency department affect timely emergency care.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Bernard Lyon · 9 Apr 2025

  “significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025Bernard Lyon9 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight delays in handing over patients from ambulances to emergency departments as a safety concern. These delays tie up ambulances and reduce the service’s ability to respond to further calls.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Bernard Lyon · 9 Apr 2025

  “significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2023 → 2025Paul Burke1 year 4 months after James Campion · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that delays in ambulance response prevented timely medical care for individuals in crisis. The core issue is the impact of service pressure on response times.

  James Campion · 20 Dec 2023

  “The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose.”

  Check it in the source

  Paul Burke · 2 May 2025

  “Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2025Paul Burke2 years 10 months after Ronald Hartley · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that excessive demand on the ambulance service leads to dangerous delays in reaching patients, forcing families to provide transport themselves.

  Ronald Hartley · 17 Jul 2022

  “when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6”

  Check it in the source

  Paul Burke · 2 May 2025

  “Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2025Paul Burke2 years 6 months after Derek Shaw · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a delay in ambulance response that prevented timely pre‑hospital emergency care, contributing to a preventable death. The core concern is the same: insufficient ambulance availability leading to delayed treatment.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  Paul Burke · 2 May 2025

  “Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Paul Burke1 year 4 months after Shaun Parks · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that delayed ambulance response times adversely affect patient outcomes by delaying necessary emergency care. The earlier report adds staffing and hospital offload issues as contributing factors, while the later report focuses on the impact of such delays on pre‑hospital care.

  Shaun Parks · 20 Dec 2023

  “The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”

  Check it in the source

  Paul Burke · 2 May 2025

  “Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025Paul Burke1 year 1 month after Jean Walker · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight delays in ambulance response caused by ambulances being held up at hospitals awaiting patient handover. The core concern is the same: hospital off‑load bottlenecks reducing ambulance availability.

  Jean Walker · 20 Mar 2024

  “The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”

  Check it in the source

  Paul Burke · 2 May 2025

  “Despite the urgency with which an ambulance was required for Mr [name redacted] no ambulance resource was available.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025James Smith10 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify ambulance handover delays at hospitals as a hazard that ties up resources and increases mortality risk for patients awaiting emergency care.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2024 → 2025James Smith1 year 1 month after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify hospital handover delays as the cause of ambulance resources being tied up, leading to longer response times and increased risk to patients.

  Jade Griffiths-Jones · 17 Apr 2024

  “if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.”

  Check it in the source

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

  Earlier report in the app · Later report in the app

• 2023 → 2025James Smith1 year 6 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify handover delays in hospitals as causing ambulance resources to be tied up and increasing response times for emergency patients. They describe the same mechanism whereby delayed handovers lead to longer waits for emergency treatment.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025James Smith1 year 6 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify handover delays at hospitals as the cause of ambulances being held outside emergency departments, which ties up ambulance resources and worsens response times.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

  Check it in the source

  James Smith · 12 May 2025

  “(2) Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2025James Smith7 months after Kevin Woods · same coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports identify handover delays in ambulances caused by inadequate social care leading to increased mortality risk. The later report focuses on specific hospitals and observable spikes, while the earlier report discusses average delays and systemic responsibility gaps.

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”

  Check it in the source

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”

  Earlier report in the app · Later report in the app

• 2016 → 2025Brian Garrick9 years after Peter Scott · different coronerIdentical hazardConfidence 0.98 · high

  Identical hazardConfidence 0.98 · high

  Both reports identify prolonged patient handover times at hospitals as causing ambulance delays and reduced availability.

  Peter Scott · 26 May 2016

  “Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Brian Garrick · 30 May 2025

  “Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2025Brian Garrick10 years after Barbara Patterson · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify delays in patient handovers at hospitals as reducing ambulance availability.

  Barbara Patterson · 21 May 2015

  “During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”

  Check it in the source

  Brian Garrick · 30 May 2025

  “Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Brian Garrick1 year 6 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports describe how prolonged patient handover delays at hospitals extend ambulance response times and keep crews unavailable.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Brian Garrick · 30 May 2025

  “Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”

  Check it in the source

  Stated action in the response to the earlier report

  “have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”

  Earlier report in the app · Later report in the app

• 2024 → 2025Brian Garrick11 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover delays at hospital emergency departments as a safety issue. These delays impede ambulance availability and increase risks to patients needing timely care.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Brian Garrick · 30 May 2025

  “Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2024 → 2025Brian Garrick1 year 1 month after Jade Griffiths-Jones · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports describe ambulance response times being delayed because patients experience long handover waits at acute hospitals, which keeps ambulances and crews off the road. The core issue is hospital handover delays affecting ambulance availability.

  Jade Griffiths-Jones · 17 Apr 2024

  “ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”

  Check it in the source

  Brian Garrick · 30 May 2025

  “Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service”

  Check it in the source

  Stated action in the response to the earlier report

  “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Ricky O'Connell1 year 3 months after Bobilya Mulonge · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify delays in ambulances clearing emergency departments as reducing the availability of vehicles to attend Category 2 calls. The core issue is the same turnaround bottleneck affecting response times.

  Bobilya Mulonge · 8 May 2024

  “Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2025Ricky O'Connell3 years 4 months after John Murphy · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify delays in ambulances clearing emergency departments as the core problem affecting response to category 2 calls. The later report confirms that this hazard persists despite prior efforts.

  John Murphy · 22 Apr 2022

  “The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”

  Check it in the source

  Stated action in the response to the earlier report

  “The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Ricky O'Connell1 year 2 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delays in ambulances clearing hospital emergency departments as a factor that impairs timely response to emergency calls.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2022 → 2025Ricky O'Connell2 years 9 months after Derek Shaw · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify that delays in ambulance attendance or turnaround contributed to a preventable death.

  Derek Shaw · 11 Nov 2022

  “Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Ricky O'Connell1 year 9 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays as reducing the service's ability to respond to emergency calls. They describe the same mechanism—excessive handover times leading to longer response intervals.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”

  Check it in the source

  Stated action in the response to the earlier report

  “have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”

  Earlier report in the app · Later report in the app

• 2024 → 2025Ricky O'Connell1 year 4 months after Jade Griffiths-Jones · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify hospital handover delays as a factor that reduces ambulance availability and worsens response times. The later report describes the same mechanism affecting a different region.

  Jade Griffiths-Jones · 17 Apr 2024

  “if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances”

  Check it in the source

  Stated action in the response to the earlier report

  “The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”

  Earlier report in the app · Later report in the app

• 2024 → 2025Ricky O'Connell1 year 5 months after Peter Beresford · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe delays in ambulances clearing emergency departments as limiting the ambulance service's ability to respond to calls, especially category 2 calls.

  Peter Beresford · 12 Mar 2024

  “delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2025 → 2025Ricky O'Connell7 months after Nicola Owens · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify hospital handover delays as a key factor reducing ambulance availability and delaying responses.

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances.”

  Check it in the source

  Stated action in the response to the earlier report

  “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”

  Earlier report in the app · Later report in the app

• 2016 → 2025Ricky O'Connell9 years 3 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delayed patient handover at hospitals as a factor reducing ambulance availability.

  Peter Scott · 26 May 2016

  “Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2025Ricky O'Connell10 years 3 months after Barbara Patterson · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify delays in ambulance hand‑over at emergency departments as a factor that reduces ambulance availability and impacts response times.

  Barbara Patterson · 21 May 2015

  “ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”

  Check it in the source

  Stated action in the response to the earlier report

  “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”

  Earlier report in the app · Later report in the app

• 2023 → 2025Ricky O'Connell1 year 11 months after Geoffery Hoad · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight excessive ambulance response times caused by delays in hospital handover or turnaround of ambulances. The earlier case describes a >14‑hour wait due to system pressure, while the later case notes that prolonged ED clearance hampers ambulance availability.

  Geoffery Hoad · 13 Sept 2023

  “Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2023 → 2025Ricky O'Connell1 year 8 months after James Campion · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that delays within the ambulance service prevented timely medical intervention. The earlier case focuses on dispatch delay, while the later case points to ambulance turnaround delays affecting response capacity.

  James Campion · 20 Dec 2023

  “The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment”

  Check it in the source

  Ricky O'Connell · 20 Aug 2025

  “The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2025Lewis Garfield9 years 5 months after Peter Scott · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight excessive ambulance-to-hospital handover times as a safety risk. The earlier report calls for strategies to improve handover, while the later report documents actual prolonged handovers causing significant lost hours.

  Peter Scott · 26 May 2016

  “one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Check it in the source

  Lewis Garfield · 28 Oct 2025

  “I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Lewis Garfield1 year 11 months after Kenneth Heard · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that the national target for ambulance-to-hospital patient handover is 15 minutes and that actual handover times far exceed this target, causing significant delays.

  Kenneth Heard · 23 Nov 2023

  “The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”

  Check it in the source

  Lewis Garfield · 28 Oct 2025

  “I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes.”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”

  Earlier report in the app · Later report in the app

• 2025 → 2025Lewis Garfield7 months after Bernard Lyon · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports describe delays in transferring patients from ambulances to emergency department care, which creates a knock‑on effect on ambulance availability.

  Bernard Lyon · 9 Apr 2025

  “significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”

  Check it in the source

  Lewis Garfield · 28 Oct 2025

  “The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2025Lewis Garfield1 year 11 months after Lynda Blackmore · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify excessive ambulance-to-hospital handover delays as a safety issue affecting emergency patient flow. They differ in the specific hospitals cited and the quantitative details of the delays.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Lewis Garfield · 28 Oct 2025

  “However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours.”

  Check it in the source

  Stated action in the response to the earlier report

  “have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”

  Earlier report in the app · Later report in the app

• 2023 → 2026Dorothy Hoyberg2 years 4 months after Geoffery Hoad · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight delays in ambulance response for Category 3 calls caused by excessive demand and limited resources. The earlier case involved a >14‑hour wait, while the later case describes a 5.5‑hour wait despite targets.

  Geoffery Hoad · 13 Sept 2023

  “The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”

  Check it in the source

  Dorothy Hoyberg · 14 Jan 2026

  “An ambulance should have reached [the deceased] within two hours but it took five and half.”

  Check it in the source

  Stated action in the response to the earlier report

  “we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”

  Earlier report in the app · Later report in the app

• 2024 → 2026Dorothy Hoyberg1 year 2 months after Simon Boyd · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that ambulance response time targets for Category 3 calls are not being met, leading to dangerous delays. They attribute the failures to rising demand outstripping service capacity.

  Simon Boyd · 6 Nov 2024

  “notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”

  Check it in the source

  Dorothy Hoyberg · 14 Jan 2026

  “Multiple attempts were made to find an ambulance resource for [the deceased] but LAS were unable to meet targets for Category 3 patients and were struggling to meet targets for Category 2 patients.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2026Dorothy Hoyberg2 years 8 months after Michael Bray · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight that prolonged ambulance response times create a risk of future deaths. They differ in the specific context: the earlier report concerns persistent Category 2 delays in the East of England, while the later report describes acute system‑wide pressures affecting Category 2 and 3 calls in London.

  Michael Bray · 22 May 2023

  “long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”

  Check it in the source

  Dorothy Hoyberg · 14 Jan 2026

  “Demand outstripped capacity. An ambulance should have reached [the deceased] within two hours but it took five and half.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2026Janet Springall1 year 9 months after Richard Carpenter · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight that delays in ambulance handover or patient waiting in ambulances increase the risk of preventable deterioration or death. The core concern is the same—ambulance delay leading to worse outcomes—though the clinical contexts differ.

  Richard Carpenter · 25 Apr 2024

  “delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion”

  Check it in the source

  Janet Springall · 7 Feb 2026

  “patients such as [the deceased] remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr11 months after Bernard Lyon · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify prolonged ambulance handover times at hospitals as a problem that ties up ambulances and reduces emergency response capacity.

  Bernard Lyon · 9 Apr 2025

  “significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2026Roman Barr1 year 8 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify ambulance handover delays at hospitals as a factor that reduces emergency availability and poses a risk of future deaths.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr10 months after James Smith · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify ambulance handover delays as a cause of reduced emergency availability and increased risk. The later report describes the same mechanism—prolonged handover times limiting ambulance resources—though in a different geographic area.

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Stated action in the response to the earlier report

  “On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”

  Earlier report in the app · Later report in the app

• 2023 → 2026Roman Barr2 years 4 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.94 · high

  Identical hazardConfidence 0.94 · high

  Both reports identify ambulance handover delays as reducing emergency response capacity and posing a risk to patients needing urgent care.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2026Roman Barr2 years 3 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports identify prolonged ambulance handover delays as a hazard that reduces emergency ambulance availability.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr1 year after Lachlan Campbell (2) · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports identify prolonged ambulance handover times at hospitals as a cause of delayed emergency response.

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Ambulance handover delays affecting emergency availability”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr1 year 1 month after Nicola Owens · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability for emergency calls. They describe the same causal chain: handover delays → ambulances stuck on premises → inability to respond to new emergencies.

  Nicola Owens · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Stated action in the response to the earlier report

  “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr11 months after Andrew Waters · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays as a problem that ties up ambulance resources and reduces emergency availability. The later report describes the same hazard with a focus on its impact during high demand.

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Ambulance handover delays affecting emergency availability”

  Check it in the source

  Stated action in the response to the earlier report

  “The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”

  Earlier report in the app · Later report in the app

• 2024 → 2026Roman Barr1 year 5 months after Kevin Woods · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify ambulance handover delays as a factor that reduces emergency availability and increases mortality risk. The earlier report links delays to systemic discharge and bed shortages, while the later report notes prolonged handover times directly causing unavailable ambulances.

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”

  Check it in the source

  Roman Barr · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”

  Check it in the source

  Stated action in the response to the earlier report

  “maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24”

  Earlier report in the app · Later report in the app

• 2023 → 2026Roman Barr2 years 5 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.92 · high

  Identical hazardConfidence 0.92 · high

  Both reports identify prolonged ambulance handover delays as reducing emergency response capacity and posing a risk to patients needing urgent care.

  Lynda Blackmore · 15 Nov 2023

  “handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”

  Check it in the source

  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2026Roman Barr1 year 9 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability and increases risk of death.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call.”

  Check it in the source

  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”

  Check it in the source

  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr11 months after James Smith · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays at hospitals as a problem that ties up ambulance resources and reduces emergency availability. The later report describes the same hazard with slightly different wording but the same core issue.

  James Smith · 12 May 2025

  “Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays”

  Check it in the source

  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”

  Check it in the source

  Stated action in the response to the earlier report

  “On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr1 year after Andrew Waters · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays at hospitals as a problem that ties up ambulance resources and reduces emergency availability.

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”

  Check it in the source

  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

  Check it in the source

  Stated action in the response to the earlier report

  “The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”

  Earlier report in the app · Later report in the app

• 2023 → 2026Roman Barr2 years 4 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover times at hospitals as a hazard that reduces emergency ambulance availability.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

  Check it in the source

  Roman Barr · 3 Apr 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2024 → 2026Roman Barr1 year 6 months after Kevin Woods · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces emergency ambulance availability and increases mortality risk.

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”

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  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”

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  Stated action in the response to the earlier report

  “developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”

  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr1 year 1 month after Lachlan Campbell (2) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover times at hospitals as a cause of delayed emergency response.

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

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  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”

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  Earlier report in the app · Later report in the app

• 2025 → 2026Roman Barr1 year after Bernard Lyon · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports identify prolonged ambulance handover times at hospitals as a problem that reduces ambulance availability for emergency calls.

  Bernard Lyon · 9 Apr 2025

  “significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up”

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  Roman Barr · 3 Apr 2026

  “Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”

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  Earlier report in the app · Later report in the app

• 2025 → 2026Geoffrey Fuller1 year 2 months after Bernard Lyon · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight significant delays in transferring patients from ambulance crews to hospital emergency departments. They describe how these delays affect ambulance availability and patient care.

  Bernard Lyon · 9 Apr 2025

  “The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”

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  Geoffrey Fuller · 18 Jun 2026

  “Significant handover delays”

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  Earlier report in the app · Later report in the app

• 2024 → 2026Geoffrey Fuller1 year 8 months after Kevin Woods · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify prolonged ambulance handover delays as a hazard that increases mortality risk by reducing ambulance availability.

  Kevin Woods · 3 Oct 2024

  “Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”

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  Geoffrey Fuller · 18 Jun 2026

  “These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”

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  Stated action in the response to the earlier report

  “developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”

  Earlier report in the app · Later report in the app

• 2025 → 2026Geoffrey Fuller1 year 2 months after Andrew Waters · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight significant ambulance handover delays at the hospital causing ambulances to be unavailable and increasing mortality risk.

  Andrew Waters · 3 Apr 2025

  “Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”

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  Geoffrey Fuller · 18 Jun 2026

  “Significant handover delays”

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  Stated action in the response to the earlier report

  “The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”

  Earlier report in the app · Later report in the app

• 2024 → 2026Geoffrey Fuller1 year 11 months after Harry Dunn: Prevention of Future Deaths Report (1) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays at emergency departments as a safety issue. They link these delays to reduced ambulance availability and increased risk of patient mortality.

  Harry Dunn: Prevention of Future Deaths Report (1) · 4 Jul 2024

  “I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”

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  Geoffrey Fuller · 18 Jun 2026

  “These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”

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  Stated action in the response to the earlier report

  “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”

  Earlier report in the app · Later report in the app

• 2023 → 2026Geoffrey Fuller2 years 7 months after Lynda Blackmore · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify ambulance handover delays as prolonging patient wait times for emergency treatment or conveyance to hospital. They describe the same mechanism—excessive handover times reducing ambulance availability and increasing mortality risk.

  Lynda Blackmore · 15 Nov 2023

  “My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”

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  Geoffrey Fuller · 18 Jun 2026

  “Significant handover delays 1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”

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  Stated action in the response to the earlier report

  “have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”

  Earlier report in the app · Later report in the app

• 2023 → 2026Geoffrey Fuller2 years 7 months after John Seagrove, Pauline Humphris and Patricia Steggles · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify prolonged ambulance-to-hospital handover delays as a safety concern. The earlier report notes worsening handover and response delays, while the later report quantifies ongoing handover delays exceeding the 15‑minute target.

  John Seagrove, Pauline Humphris and Patricia Steggles · 23 Nov 2023

  “What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”

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  Geoffrey Fuller · 18 Jun 2026

  “On arrival at Royal Cornwall Hospital (RCHT), Mr [name redacted] spent a further 2 hours and 52 minutes before being handed over to the emergency department.”

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  Earlier report in the app · Later report in the app

• 2025 → 2026Geoffrey Fuller1 year 4 months after Lachlan Campbell (2) · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify delays in handing over patients from ambulances to the emergency department at Royal Cornwall Hospital as a safety concern. The later report provides detailed data showing the handover delays persist beyond the NHS target.

  Lachlan Campbell (2) · 28 Feb 2025

  “Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”

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  Geoffrey Fuller · 18 Jun 2026

  “The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”

  Check it in the source

  Earlier report in the app · Later report in the app