Lewis Garfield
28 Oct 2025 · Coroner Hassan Shah · Northamptonshire
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate information recording and conveyance by SCAS
“It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.”
2. delayed medical review of emergency call
“The first call was at around 00:44 hours but it was not until over 4 hours later at 05:05 hrs that a medically trained clinician first reviewed the facts, immediately escalating it to category 1.”
3. lack of guidance to family on patient handling
“The family complained of not being given any guidance on how to deal with the patient pending the arrival of an ambulance e.g. not to move him given the fall down the stairs.”
4. excessive ambulance handover delays
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes. However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours. The Trust lost 115 hours waiting to handover at Northampton over 121 hours at Kettering.”
5. ineffective mitigation of handover delays
“I heard evidence that steps are being taken to mitigate the impact of pressures in the healthcare system. University Hospitals of Northamptonshire have adopted the '45- minute handover' approach. Despite this, on the day of the inquest on 27 October 2025, average handover times at Northampton General Hospital were 1 hour 11 minutes and I suspect that this will get worse during the full onset of winter pressures.”
6. persistent ED boarding delays
“The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes.”
Closely relatedConfidence 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.”
This report
“However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours.”
Identical hazardConfidence 0.90 · high
Earlier report
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”
This report
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes.”
Closely relatedConfidence 0.90 · high
Earlier report
“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”
This report
“The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.”