Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Albert James Hand · 9 Jan 2014 · Tom Osborne, Bedfordshire & Luton
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
What was promised
Stated action 1 · response to Albert James Hand (9 Jan 2014) · stated timescale: 2013
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
judiciary.uk/…/2014-0010-Response-by-East-of-England-Ambulance-…
Stated action 2 · response to Brian Mills (17 Nov 2016) · stated timescale: none stated
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
judiciary.uk/…/2016-0416-Response-by-East-of-England-Ambulance-…
Stated action 3 · response to Christopher Williams (31 May 2019) · stated timescale: none stated
“the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls”
judiciary.uk/…/2019-0183-Response-by-East-of-England-Ambulance-…
4 further stated actions are listed on the full chain page.
What recurred
- 17 Nov 2016 · Brian Mills · Geoffrey Sullivan
- 31 May 2019 · Christopher Williams · Yvonne Blake · Closely related · confidence 0.85 (high)
- 26 Aug 2022 · Barbara Hollis · Jaqueline Lake · Closely related · confidence 0.90 (high)
- 26 Aug 2022 · Christina Ruse · Jacqueline Lake · Closely related · confidence 0.90 (high)
- 15 Jan 2024 · Dennis King · Darren Stewart · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Barbara Hollis · 26 Aug 2022
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Later · Dennis King · 15 Jan 2024
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
What happened next
No evidence found either way · stated action 1
The East of England Ambulance Service's 2025-2026 Annual Quality Account does not mention a Clinical Capacity Review or funding requirements from 2013.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“A new co-responding pilot which will see volunteers from St John Ambulance respond to 999 calls has been launched in Norfolk. The post [Ambulance service partners with St John Ambulance to launch co-responding pilot](https://emergencyservicestimes.com/2026/05/05/ambulance”
East of England Ambulance Service Archives - Emergency Services Times · emergencyservicestimes.com/…/feed
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“6.4 Emergency Preparedness, Resilience, and Response (EPRR) 23”
2026/27 ambulance emergency and urgent care service ... · aace.org.uk/…/PRN02107-26-27-ambulance-emergency-and-urgent-car…
“This document has been approved by the Trust Board and is an accurate account of the level of quality of service provided to patients.”
Annual Quality Account 2025-2026 | EEAST · eastamb.nhs.uk/reports/annual-quality-account-2025-26
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
The Trust states it is working with HSIB to escalate concerns but does not specify any completed action or timeline.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
“The trust's Patient Plan included that hospitals would no longer be the default destination for patients if it was safe for them to instead receive care closer to home.”
East of England Ambulance to take fewer patients to hospital · bbc.com/news/articles/cy49d8zv4w2o
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust is working hard with our system partners across the region to ensure that our patients are safe during this challenging period. Like all other ambulance trusts, we are also working with the Healthcare Safety Investigation Branch (HSIB) to continue to escalate our concerns.”
The Trust states it is working with HSIB to escalate concerns but does not specify any completed action or timeline.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
“The trust's Patient Plan included that hospitals would no longer be the default destination for patients if it was safe for them to instead receive care closer to home.”
East of England Ambulance to take fewer patients to hospital · bbc.com/news/articles/cy49d8zv4w2o
No evidence found does not mean the action did not happen.
No evidence found either way · a stated action in a response
“Escambia County Emergency Medical Services](/story/news/local/escambia-county/2024/02/06/escambia-ems-leaders-vote-no-confidence-in-chief-david-torsell/72480321007/) is making some changes to improve patient safety including purchasing nearly $2 million dollars in new equipment and approving new agreements with local healthcare”
Escambia County EMS ambulance response times to improve · pnj.com/…/77064995007
No evidence found does not mean the action did not happen.