Andrew Lewis
19 Dec 2024 · Coroner Heidi Connor · Berkshire
This report repeats 8 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed ambulance arrival
“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.”
2. sustained high operational pressure
“SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.”
3. persistent operational pressure
“The lowest escalation level that this ambulance service has been at in this period is REAP 2. They have never been at steady state (REAP 1) during this period.”
4. ambulance queuing delays
“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).”
5. lack of oversight of ambulance delays
“There appears to be no oversight of this issue, and a number of ambulance trusts have not responded to these reports at all.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“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 hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
This report
“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.”
Closely relatedConfidence 0.85 · high
Earlier report
“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.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“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.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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).”
Closely relatedConfidence 0.85 · high
Earlier report
“The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“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.”
This report
“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).”
Identical hazardConfidence 0.94 · high
Earlier report
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
This report
“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). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.”
Closely relatedConfidence 0.90 · high
Earlier report
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour”
This report
“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.”
Identical hazardConfidence 0.90 · high
This report
“SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.”
Later report
“On 19 June 2025 London Ambulance Service (LAS) were operating at REAP Level 4 (extreme pressure) and by 9am that day, targets were being breached.”
Responses
2024-0697-Deaths-in-the-NHS_-Ambulance-Trusts.pdf ↗· Department of Health and Social Care
Stated action
“The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published.”
2024-0697-Response-from-DHSC.pdf ↗· Department of Health and Social Care
2024-0697-Response-from-NHS-England.pdf ↗· NHS England