Skip to content
recurance

Geoffrey Fuller

18 Jun 2026 · Coroner Guy Davies · Cornwall & the Isles of Scilly

This report repeats 13 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. ambulance handover delays

    “Significant handover delays”
  2. 2. emergency department crowding

    “Emergency department crowding”
  3. 3. insufficient social care provision

    “Insufficient social care provision”

Linked reports

Repeats an earlier warningMohan Acharya27 Feb 2020 · 6 years 4 months earlier
Identical hazardConfidence 0.95 · high

Earlier report

“Emergency department crowding is associated with increased mortality amongst admitted patients;”
Original on judiciary.uk ↗

This report

“On the day of Mr [name redacted] ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients.”
Full chain: Overcrowded emergency department increases patient mortality
Repeats an earlier warningLynda Blackmore15 Nov 2023 · 2 years 7 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Original on judiciary.uk ↗

This report

“Significant handover delays 1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJohn Seagrove, Pauline Humphris and Patricia Steggles23 Nov 2023 · 2 years 7 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
Original on judiciary.uk ↗

This report

“On arrival at Royal Cornwall Hospital (RCHT), Mr [name redacted] spent a further 2 hours and 52 minutes before being handed over to the emergency department.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningKenneth Heard23 Nov 2023 · 2 years 7 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
Original on judiciary.uk ↗

This report

“The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.”
Full chain: Insufficient social care provision leading to discharge delays
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 1 year 11 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
Original on judiciary.uk ↗

This report

“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningDennis Harry22 Sept 2024 · 1 year 9 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
Original on judiciary.uk ↗

This report

“The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS.”
Full chain: Insufficient social care provision leading to discharge delays
Repeats an earlier warningKevin Woods3 Oct 2024 · 1 year 8 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Original on judiciary.uk ↗

This report

“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJunior Powell2 Dec 2024 · 1 year 6 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion”
Original on judiciary.uk ↗

This report

“The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS.”
Full chain: Insufficient social care provision leading to discharge delays
Repeats an earlier warningDorothy Reid4 Feb 2025 · 1 year 4 months earlier
Closely relatedConfidence 0.87 · high

Earlier report

“there are a significant number deaths associated with long waits in the emergency department”
Original on judiciary.uk ↗

This report

“Such long delays increase the risk of mortality.”
Full chain: Overcrowded emergency department increases patient mortality
Repeats an earlier warningLachlan Campbell (2)28 Feb 2025 · 1 year 4 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Original on judiciary.uk ↗

This report

“The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningAndrew Waters3 Apr 2025 · 1 year 2 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”
Original on judiciary.uk ↗

This report

“Significant handover delays”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningBernard Lyon9 Apr 2025 · 1 year 2 months earlier
Closely relatedConfidence 0.92 · high

Earlier report

“The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”
Original on judiciary.uk ↗

This report

“Significant handover delays”
Full chain: Delayed ambulance handover at hospitals
Repeats an earlier warningJames Smith12 May 2025 · 1 year 1 month earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital”
Original on judiciary.uk ↗

This report

“Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients.”
Full chain: Insufficient social care provision leading to discharge delays

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error