Dennis King
15 Jan 2024 · Coroner Darren Stewart · Suffolk
This report repeats 3 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance transfers
“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”
2. confusion in transfer categorisation
“Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals”
3. inadequate centralised care delivery
“The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate”
4. inadequate action plan
“Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
This report
“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.”
Closely relatedConfidence 0.85 · high
Earlier report
“There were no emergency ambulances available to assign to this call due to high call demand.”
This report
“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.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Closely relatedConfidence 0.85 · high
This report
“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.”
Later report
“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”
Responses
2024-0020-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2024-0020-Response-from-East-of-England-Ambulance-Service-.pdf ↗· East of England Ambulance Service
2024-0020-Response-from-NHS-Trust.pdf ↗· Department of Health and Social Care
Stated action · 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery”