Inadequate patient handover practices
Welsh Ambulance NHS Trust received 2 coroners' reports about this hazard between 14 Mar 2017 and 20 Feb 2023.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
Original on judiciary.uk ↗ Welsh Ambulance NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The plan addresses the main causes of Unscheduled Care pressure through reducing admissions (demand), reducing DTOCs and length of stay (supply) and addressing flow at the front of hospitals to protect minors from long waits. It also includes reducing ambulance handover delays.”
- 5 years 11 months later
Raised again · 1st time
David Strachan↗
20 Feb 2023 · Kate Sutherland · North Wales (East and Central)
Closely relatedConfidence 0.90 · higha different coroner“there were significant handover delays across all BCUHB sites.”
Original on judiciary.uk ↗ Repeated from the earlier report:handoverdelays
Welsh Ambulance NHS Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Welsh Ambulance NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2023David Strachan5 years 11 months after Rebecca Evans · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight significant delays in the handover of patients from ambulances to emergency departments. The later report notes these delays persist across all health board sites despite ongoing efforts.
Rebecca Evans · 14 Mar 2017
“current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
Original on judiciary.uk ↗ David Strachan · 20 Feb 2023
“there were significant handover delays across all BCUHB sites.”
Original on judiciary.uk ↗
Stated action
“The plan addresses the main causes of Unscheduled Care pressure through reducing admissions (demand), reducing DTOCs and length of stay (supply) and addressing flow at the front of hospitals to protect minors from long waits. It also includes reducing ambulance handover delays.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Welsh Ambulance NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2023 | 0.70 | 0.06 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.