Delayed ambulance response to critically unwell patient
Welsh Ambulance Service NHS Trust received 3 coroners' reports about this hazard between 20 Apr 2016 and 6 Jul 2023.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes.”
Original on judiciary.uk ↗ Welsh Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”
Stated timescale: 9 June 2016
- 2 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
Original on judiciary.uk ↗ Repeated from the earlier report:hoursambulance
Welsh Ambulance Service NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust acknowledges your concerns regarding our lack of resourcing, which meant that there was a significant delay in attending to a critically unwell patient.”
- 4 years 9 months laterIdentical hazardConfidence 0.90 · higha different coroner
“the delay in the attendance of the ambulance is significant and unacceptable.”
Original on judiciary.uk ↗ Repeated from the earlier report:delayambulance
The most recent report. A response may not be due or published yet.
- All reports to Welsh Ambulance Service NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2016 → 2018Andrew Collins2 years 5 months after Ronald Hamer · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports describe a significant delay in ambulance arrival despite correct prioritisation, caused by insufficient resources or high demand.
Ronald Hamer · 20 Apr 2016
“As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes.”
Original on judiciary.uk ↗ Andrew Collins · 2 Oct 2018
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
Original on judiciary.uk ↗ 2018 → 2023Emlyn Roberts4 years 9 months after Andrew Collins · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a dangerous delay in ambulance attendance caused by insufficient resources. They describe the same underlying hazard of delayed response to deteriorating patients.
Andrew Collins · 2 Oct 2018
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
Original on judiciary.uk ↗ Emlyn Roberts · 6 Jul 2023
“the delay in the attendance of the ambulance is significant and unacceptable.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust acknowledges your concerns regarding our lack of resourcing, which meant that there was a significant delay in attending to a critically unwell patient.”
Stated action · timescale: 9 June 2016
“Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”
Stated action
“The Trust acknowledges your concerns regarding our lack of resourcing, which meant that there was a significant delay in attending to a critically unwell patient.”
No published response from Welsh Ambulance Service NHS Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Welsh Ambulance Service NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2018 | 0.70 | 0.15 | Closely related · 0.90 | different |
| 2018 → 2023 | 0.80 | 0.14 | Identical · 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.